Employee Self Verification Form

Applicant No/ Employee ID RAS-AP-193 GUNTUR
Location
Date of Joining/Interview 16-12-2010
Please provide complete and correct information. All fields are mandatory. Please do not use short forms / abbreviations.
Personal Details Full Name (First, Middle, Last) SHAIK Khudavan Former Name(s) / Maiden Name (if applicable) Gender: Male Female Date of Birth (dd/mm/yy) 12-06-1989 Remarks If Any
Fathers Name Mothers Name Wifes/Husbands Name (If applicable) Other Family Members Name. Relation Residence No
Shaik.Khasimpeera Madarbi no
Shaik mastanvali Brother Mobile No 9704820426 Mobile no. of family member 8008530115
Complete Address Building/Apt. Name: Current Address H.No/D.No/Flat No: 4-115 Street/ Colony Name: Location: Gottipadu Landmark: Near Urdu School City: Guntur Pin code: 5220019 Own House/ Rented :: Own House owner Phone No. and Name Complete Address
Permanent Address
Building/Apt. Name : H.No/D.No/Flat No : Street/ Colony/Village Name : Location: Landmark: City: Pin code: Gram Panchayat Head Name :: Ph. No. ------------ DO -------------
Complete Address of any Family Members Current Address Building/Apt. Name: H.No/D.No/Flat No: Street/ Colony / Village Name: Location: Landmark: City: Pin code: -------------- DO -------------------
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Education Qualification
Educational Record (1) - Highest Qualification (Please attach copy of degree certificate and final year mark sheet.) College Name (Full) Hindu College Guntur School Name (Full) Z.P.H School Location Gottipadu University Name (Full) Location Location
School/College Address (Full address with City and Pin code)
Hindu College, Guntur, Beside Guntur Market.
University Name and Address
From (month / year)
To (month / year)
Graduated Yes No
Program Full Time Part Time
Roll No / Enrollment No.
Type of degree/qualification
Graduation date (month / year)
Subject Major
Copy of Certificate Attached
Yes
No
i. Character Certificate
ii. Address Certificate
Mukhiya / Sarpanch / SDO Court (Issued within Six month) Voter Identity / Rashan Card / Residential Certificate
Final Year Mark sheet Attached
Yes
No
Page 3 of 6
Employment Section
Ensure that you are descriptive wherever necessary e.g. If Co. is closed, do mention it. Employee Code/ ID/ Number are mandatory. If your last employer did not provide one, please mention and state reasons for the same.
Details of Last Employer
Please attach a copy of your last Pay slip & relieving letter/service certificate/Resignation acceptance on letter head Company Name (1) : Prithvi Informationsolutions ltd Last Designation Rigger Department O&M
Address(worked) Hyderabad
Address (Corporate Office Prithvi house, #2-56/2/19, Khanamet, Madhapur, Hyderabad.
Office Telephone (where worked) 040 44856019
Office Telephone (Corporate Office) 040 44856019
Employment Period: (date, month, year) From 01-11-2010 To 15-12-2010
Employee Code/ Personnel No:
Remunerations (Gross Salary/month or P.A) 8500/PM
REPORTING MANAGER DETAILS (Mandatory) Name: Seshagiri Rao Designation: : Asst vp Department Contact No
Email ID of Reporting Manager: HUMAN RESOURCES MANAGER DETAILS (Mandatory) Name: Praveena Designation: HR Contact No ((Mandatory)
Email ID of HR Manager (IF AVAILABLE): Reason(s) for Leaving Contract changed
Page 4 of 6
Details of Previous Employer

Please attach a copy of your last Pay slip & relieving letter/service certificate/Resignation acceptance on letter head Company Name (2) Last Designation Department
Address (where worked):
Address (Corporate Office)
Office Telephone (where worked)
Office Telephone (Corporate Office)
Employment Period: (date, month, year) From To
Employee Code/ Personnel No:
Remunerations (Gross Salary/month or P.A)
REPORTING MANAGER DETAILS (Mandatory) Name: Designation: Email ID of Reporting Manager: HUMAN RESOURCES MANAGER DETAILS (Mandatory) Name: Designation: Contact No ((Mandatory) Department: Contact No
Email ID of HR Manager (IF AVAILABLE): Reason(s) for Leaving
Page 5 of 6
Self Declaration and Authorization

I understand that any employment by ____Company Name____ or its affiliated companies is conditioned upon positive responses from my references, bonding eligibility, continued adherence to ____________________ policies and procedures, applicable rules and regulations and job performance satisfactory at all times to ____________________. I consent to take any pre or post-employment examinations and or verification/checks as may be required by ____________________ or its representative. I further authorize ____________________ to make inquiries by written communication, by telephone, or in persons to any former employer, government, agency, educational institution, state police or any other regulatory, compliance body or organization or any other persons or institutions knowledgeable of my background, prior history, work experience, nature of duties, CTC, performance levels, reliability, responsibility, honesty and any other measures of my character or personality. I release ____________________ from any liability that may arise from such examination and/or verification/checks. Former employers and officials of education institutes, named on this application are authorized to give information about me and I release them from all liability for issuing such information. I hereby attest and warrant that all my answers on this application as well as on all forms completed in conjunction with my employment are true and accurate. I understand that my misrepresentation of facts, failure to disclose information required on this application or material change in my information provided which is not reported to Human Resources shall be cause for dismissal regardless of when discovered by ____________________. A Photostat or any other copy of this instrument bearing my signature shall be equally legally valid as the original
Signature FULL Name (In Block Letters) SHAIK. Khudavan Date 25-07-2012 Place Guntur
Page 6 of 6

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Applicant No/ Employee ID RAS-AP-193 GUNTUR

Date of Joining/Interview 16-12-2010

School/College Address (Full address with City and Pin code)

Hindu College, Guntur, Beside Guntur Market.

University Name and Address

From (month / year)

Program Full Time Part Time

Roll No / Enrollment No.

Graduation date (month / year)

Copy of Certificate Attached

Final Year Mark sheet Attached

Address (Corporate Office Prithvi house, #2-56/2/19, Khanamet, Madhapur, Hyderabad.

Office Telephone (where worked) 040 44856019

Office Telephone (Corporate Office) 040 44856019

Employment Period: (date, month, year) From 01-11-2010 To 15-12-2010

Employee Code/ Personnel No:

Remunerations (Gross Salary/month or P.A) 8500/PM

Email ID of HR Manager (IF AVAILABLE): Reason(s) for Leaving Contract changed

Details of Previous Employer

Address (where worked):

Address (Corporate Office)

Office Telephone (where worked)

Office Telephone (Corporate Office)

Employment Period: (date, month, year) From To

Employee Code/ Personnel No:

Remunerations (Gross Salary/month or P.A)

Email ID of HR Manager (IF AVAILABLE): Reason(s) for Leaving

Self Declaration and Authorization

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