BACKGROUND VERIFICATION FORM

Please provide complete and correct information. All fields are mandatory. Please do not use short forms / abbreviations. Please use only Capital Letters while filling up the form.

Personal Details

Full Name (First, Middle, Last) : TAPAS KUMAR MONDAL

Former Name(s) / Maiden Name (if applicable): Gender: Male Female

Date of Birth (dd/mm/yy): 19/02/89 Mobile Number: 9641671001 , 9563308808

Father’s name: BENUKAR MONDAL Marital Status: UNMARRIED

Name of Spouse: NA Number of Children: NA

National Identification Details

Passport No./PAN No./DL/Voter ID/Aadhar no.

Place of Issue Date of Issue Expiry Date

AADHAR CARD7109 3406 2014

KANDI NA NA

Details of Addresses (Please attach a copy of the Address Proof)

Complete Address with Pin Code (stay in last 5 years)

Complete Address along with Landline & Mobile Number:

Period of Stay: From: (mm/yyyy) To: (mm/yyyy)

Current Residential Address (along with Prominent landmark

C/O R. B. THAPA, NEW COLONY, BELOW FIRE STATION, JORETHANG, SOUTH SIKKIM -737121

07/2011 - TILL DATE

Emergency contact (Name & Telephone Number)

9775402046

EducationPlease provide details of Highest completed Education/Qualification (Graduation/Post Graduation/HSC/SSC& others degree/diploma (if any)) : DIPLOMA

College Name & Address: SILIGURI GOVERNMENT POLYTECHNIC, DABGRAM, SILIGURI - 734006

University Name: WEST BENGAL STATE COUNCIL OF TECHNICAL EDUCATION

From (mm/yyyy) To (mm/yyyy) Diploma Completed

Type of Program Student ID No./Enrolment No./Registration No./Hall Card No /Roll No.

06/2008 06/2010 Yes NoPursuing

Part –TimeFull – Time Correspondence

REGISTRATION NO. D031237079901

Type of Qualification(degree, certificate, diploma)

Graduation date (mm/yyyy) Specialization

DIPLOMA IN ENGINEERING 02/09/10 ELECTRONICS & TELECOMMUNICATION

Previous Employment History (Employment 1) (If any Break/rejoining, please specify)

Name & Address of the Company:

SIBIN GROUP, INDIRA BYEPASS ROAD, NEAR COIR BHAWAN, GANGTOK

Telephone: Designation at the time of leaving& department

Employee code / Personnel code & OHR id/others (if any)

03592-232648 ELECTRICAL SUPERVISOR NA

Period From (dd/mm/yyyy) Period To (dd/mm/yyyy) Last Reporting Manager (Name & Designation), Contact No/ Ext, E-Mail ID:

20/08/2010 12/07/2011 JAGANNATH BHATTACHARYYA, MANAGER (IT & ET)

Email : jagannath@sibingroup.com

Contact: 9475009898

Salary/Remuneration Detail

(CTC Per Annum)

Nature of employment(Full Time/Part Time/Trainee/Contractual/other)

Agency(outsourcing company)details along with contact numbers

(If contractual)

96000 CONTRACTUAL NA

Reason for leaving: Better Opportunity

Can a reference be taken now? Yes No

(If no, when can it be taken?)

- To enter further educational detail, please do copy and paste above format of educational detail.- Please attach supporting documentary proof against each qualification

mentioned.(degree/diploma/provisional certificate/Grade sheet/All year mark sheet/others if any)

- To enter further Address detail, please do copy and paste above format of Address details. - Please attach supporting documentary proof for National id mentioned above along with address

proof for all the addresses.

Reference Check

Please provide the details of professional References that are associated with you (Person should not be a relative or unemployed.

- To enter further employment detail, please do copy and paste above format of employment detail.- Please attach supporting documentary proof against each employment mentioned.(Relieving

Letter/Experience letter, Salary slips, others if any)

Previous Employment History (Employment 2) (If any Break/rejoining, please specify)

Name & Address of the Company:

SIMFED, GINGER PROCESSING UNIT, BIRDANG, WEST SIKKIM

Telephone: Designation at the time of leaving& department

Employee code / Personnel code & OHR id/others (if any)

03592-202429/223432 BOILER OPERATOR & MACHINE INCHARGE

NA

Period From (dd/mm/yyyy) Period To (dd/mm/yyyy) Last Reporting Manager (Name & Designation), Contact No/ Ext, E-Mail ID:

15/07/2011 TILL DATE YOGESH GURUNG

Email: yogez@yahoo.com

Contact: 9933119903

Salary/Remuneration Detail

(CTC Per Annum)

Nature of employment(Full Time/Part Time/Trainee/Contractual/other)

Agency(outsourcing company)details along with contact numbers

(If contractual)

1.5 Lakhs CONTRACTUAL NA

Reason for leaving: Can a reference be taken now? Yes No

(If no, when can it be taken?)

Letter of AuthorizationTo whom it may concern

I understand that Client Name may hire an agency to verify and validate the information I have provided including my employment, my personal background, professional standing, work history and qualifications.

I understand that an external background agency may obtain information it deems appropriate from various sources including, but not limited to, the following: past employers, criminal conviction records, school records, College records and professional and personal references.

I authorize, without reservation, any individual, corporation or other private or public entity to furnish Client Name and the outside background agency all information about me.

I unconditionally release and hold harmless any individual, corporation, or private or public entity from any and all causes of action that might arise from furnishing to Client Name and the eternal agency information that they may request pursuant to this release.

This authorization and release, in original, faxed or photocopied form, shall be valid for this and any future reports and updates that may be requested.

Candidate Signature: ________________________

Name in Block Capitals: ________________________

Date of Birth (dd/mm/yyyy): ________________________

Date: ________________________

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