Background Verification Form
(Please read carefully before filling up the form)
Instructions:
All Sections are mandatory
Dates to be mentioned in DD/MM/YYYY format
Supporting Documents to be submitted:
Education
o Highest Degree Mark sheet and Degree Certificate OR Provisional Certificate from the college/university declaring
the Student ID and Duration of Course.
o All semester mark sheets of your highest degree
Employment
o Employment Letters
1
Section A:
Information Release Form
I hereby authorize to contact / carry out all Background Checks not restricted to education and employment before and during
the period of current and subsequent projects. I authorize former employers, agencies, educational institutes etc. to release
any information pertaining to my employment/education or any such information as may be needed to conclude the back
ground check and I release them from any liability in doing so.
I confirm that my appointment is based on the information furnished by me in my employment application and all further
declarations and undertakings. Hence, any false statement or information furnished as above and/or furnished during the
period of my employment, will result in action based on company policy including dismissal without notice.
Signature of the employee
Your Name:
Date:
2
Section B:
Personal Details:
Name: _________________________________________________________________________________
Maiden / Former Name: ___________________________________________________________________
(Please update only if there was a change in name)
Gender:_________________________________ Date of Birth (DD/MM/YYYY) :______________________
Marital Status: ___________________________ Spouse Name : __________________________________
Contact Number: _________________________ Personal Email ID : _______________________________
Father’s Name: ________________________________
3
Address Details:
(Please provide address for last 7 years as applicable)
Start Date (MM/YYYY)
Current Address
1 (Complete address with
Pin Code) End Date (MM/YYYY)
Start Date (MM/YYYY)
Permanent Address
2 (Complete address with
Pin Code) End Date (MM/YYYY)
Start Date (MM/YYYY)
Immediate Previous
3 address - I (Complete
address with Pin Code) End Date (MM/YYYY)
Start Date (MM/YYYY)
Immediate Previous
4 address - II (Complete
address with Pin Code) End Date (MM/YYYY)
Start Date (MM/YYYY)
Immediate Previous
5 address - III (Complete
address with Pin Code) End Date (MM/YYYY)
Start Date (MM/YYYY)
Immediate Previous
6 address - IV (Complete
address with Pin Code) End Date (MM/YYYY)
4
Educational Qualification:
Sr. Details Post Graduation Details (Master Degrees)
1 Highest degree Obtained
2 Year of Passing
3 Seat/Roll _Number
4 University Name
5 College Name and Address
5
Sr. Details Graduation Details (Degree/Diploma Certifications)
1 Highest degree Obtained
2 Year of Passing
3 Seat/Roll _Number
4 University Name
5 College Name and Address
6
Under Graduation Details( PUC / Senior Secondary/+2/ 12
Sr. Details
Certificate)
1 Highest degree Obtained
2 Year of Passing
3 Seat/Roll _Number
4 University Name
5 College Name and Address
7
Employment Details:
Mention expected date to freelance this project: __________________________________
Mention expected date of editing concept paper:
Sr. Previous company Previous company Previous company Previous company
Details
No 1 2 3 4
Employer Name and
complete address
(Payroll company)
Payroll Company
Status :
Active/Closed
In case you were
deployed at an
alternate company,
please mention the
company
name(Client Name)
2 Employee Code
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Sr. Previous company Previous company Previous company Previous company
Details
No 1 2 3 4
3 Work location
Previous Name of
the company if
4
merged/Name
Changed
5 Reason for leaving
Start Date Start Date Start Date Start Date
Dates Employed
6
(DD/MM/YYYY) End Date End Date End Date End Date
9
Reference Details:
Sr. Reference Reference Reference Reference
Details
No 1 2 3 4
Full Name of
1
Reference
2 Contact Number
3 Official E-Mail ID
4 Designation
5 Company Name
10
GAP Details:
From (MM/YYYY) To (MM/YYYY) Reason
NOTE** Please specify GAPS (if any) between Education & Employment.
One education to another education or
Education to employment or
One employment to another employment
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Self-Declaration
I hereby Declare the following:
1. Convicted by law for any criminal offence in the last 7 years (Yes/No) :__________
2. Open criminal cases against me with any law enforcement authorities or any judicial court (Yes/No):__________
3. Part of the board of director/s in any company (Yes/No) :__________
Note: In case you have answered as “Yes” to any of the above questions, please provide details on the same:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
I declare that the above information is true. I am aware and acknowledge that Capgemini India can take appropriate action as
per the company policy if they find any negative remarks antecedents against me pertaining to the background verification
which may include immediate termination of my employment.
Signature of the project freelancer
Name of the project freelancer:
Date (DD/MM/YYYY):
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