Work Related Information

Company Name MindTree Limited

Corporate ID
Work Address Emp Id: M1012511, MindTreet Ltd TP2/2 Cyber
Vale, Ascendas IT Park,
Mahindra World City SEZ, Natham Sub-Post, Chengalpet,
Personal Information City Chennai Pin 603002
Name as desired on the card (Maximum 20 Characters including word space)
Priyadharsini Tel 044-67497000 Extn. 97129 Fax 044-67497100
(Please underline your family name)
Title Ms. Official E-mail address priyadharsini_subbarayan@mindtree.com

Gender Female Your Designation Senior Associate

Years with Company 0.2 Employee No. M1012511

Name of Applicant Priyadharsini Subbarayan

If less than one year with the current company, please also provide
22/07/1985 details of your previous employer: Applicant's Signature
Nationality Indian Date of Birth
DD/MM/YY SIGNATURE IN ORIGINAL
Company Name Teklogiq Information Systems
PAN/GIR No. AQUPP1959R D D M M Y Y
Position in Company: Senior Software Engineer 0 2 0 8 1 0
22/05/2018 Applicant's Name: Priyadharsini
Passport No: G8573580 Date of Expiry
DD/MM/YY City Chennai Tel. 044- 42329640 Declaration by the Company:
Financial Information On behalf of the company named in this application ("the company"), I here by request
issuance of an Corporate Card to the individual named above and certify that named
Driving License No: - Gross annual taxable Income (Rupees): 378,944.05 individual is an employee of the company. I declare and undertake that a photocopy of one
photo identification (Valid PAN Card/Passport* /Driving Licence*/ Electoral Card*) and one
proof of address (Latest Bank Statement/ Utility Bill/ Ration Card) of the applicant are
Residential Address 93-A, Type-2 Quarters (Please attach latest copy of TDS 16/last income tax return available with the company and can be provided to AEBC for verification pruposes as and
acknowledged by ITO or latest salary certificate from employer) when required. I confirm that the information given in this application form is true and
Block-7 correct and that the company hereby agrees to be bounde by the American Express
Corporate Cardmember Agreement which will be sent along with the Corporate Card.
Details of your personal bank account:
City: Neyveli Township PIN: 607803 Name of Bank ICICI
Address Cenotaph Road
Tel: Mobile: 9942514031 * Also Valid for address proof.
City Chennai Pin Signature of Authorised Signatory and Company Seal
Are you a current/past American Express Card Member? Tel. Account No. 101560092
NO
If Yes, Please give Card Number(s) Additional Information D D M M Y Y
Address to which we should mail your Billing Statements:
Work Name of Authorised Corporate Signatory
Please Sign me up for Express Cash Facility*:
Yes No Designation: Tel:
*The request is valid and will be processed only if your company is
enrolled for this facility