Employment Application Form

If you have already registered on our IBM Job Portal please provide the IBM Candidate Applicant ID also called GOM
Candidate Applicant ID. If you are referred by an Agency, please ask your agency for the Applicant ID

IBM Application ID *

GBS-A36895453-17837906
Please affix your passport size photo here

FILL ALL DETAILS IN CAPITAL LETTERS

Mr.

*Title

* Enter your name as per your Passport, Driver's Licence, PAN Card or Or any Govt issued Photo Identity card (For Indian
Nationals)

Middle Name

*First Name / Given Name

ANSUMAN

Father's Name

*Last Name / Family Name

SATAPATHY

ASHOK KUMAR SATAPATHY

*Date of Birth

*Mobile Number

DD

MMM

YYYY

13

Oct

1993

Country Code

+91

Mobile Number

8018020526

Telephone (Landline)

*Personal Email ID

City Code

Country Code

asatapathy2013@gmail.com

+91

PAN Card

0661

Phone Number

2462522

Passport Number
M0986363

Place of Issue of Passport

Expiry Date

BHUBANESWAR

DD

MMM

26

Aug

Country Of Birth

*Nationality
INDIAN

INDIA

YYYY

2024
City Of Birth
CHATRAPUR

*SOURCE INFORMATION - How did you know about this vacancy in IBM? (Select any one of the below)
Agency
Employee
Referral

Enter Agency name

Name of the Employee
(Referrer Name)

Referrer's employee
Number

Referrer's E- Mail ID
Job Site
X

Enter the jobsite name

here

Direct

Page 1 of 8, Employment Application form V 02, wef - 11th May 2015

Social Networks (Website

Name -Facebook/ LinkedIn/
Twitter/ Google+)

EDUCATION DETAILS (Fill in CAPITAL Letters)

Please complete all fields, even if you have already provided a resume. Provide details on COMPLETED degree programs only.
*Highest Qualification (Completed)

B.TECH

** e.g.: M.Sc, B.Com

**Highest completed degree / diploma awarded by a University / Board or its affiliates and or approved by UGC / AICTE / Ministry of HRD / Government of India

Course Tenure

Qualification

Start Date
SSLC (10th)

End Date
Year Of Passing

Start Date
HSLC ((12th))

End Date
Year Of Passing

Start Date
Graduation

Complete Name & Address of School / College / Institution and

Name of the University
*University name is mandatory where applicable(DO NOT ABBREVIATE)

End Date
Year Of Passing

MMM

YYYY

Apr

2008

Mar

2009

May

2009

School/
College/
Institution
details (Name
& Address

Percentage/
Grade Points

Registration /
Roll / Final
Year Seat
Number

Name of the
Degree
Awarded
(e.g.. B.com /
BA/ Mtech)

89%

5183333

Xth

86.80%

6606414

XIIth

8.29

B312007

B.TECHEEE(Electronics
and Electrical
Engg.)

DEEPIKA ENGLISH MEDIUM SCHOOL ,SEC-5 ROURKELA 769003

CENTRAL BOARD OF SECONDARY EDUCATION, BHUBANESWAR

University
Details (Name
& Address) if
applicable

MMM

YYYY

Apr

2010

Mar

2011

May

2011

School/
College/
Institution
details (Name
& Address

DEEPIKA ENGLISH MEDIUM SCHOOL ,SEC-5 ROURKELA 769003

CENTRAL BOARD OF SECONDARY EDUCATION

EDUCATION, BHUBANESWAR
University
Details (Name
& Address) if
applicable

MMM

YYYY

Sep

2012

May

2016

May

School/
College/
Institution
details (Name
& Address

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY ,BHUBANESWAR

2016
University
Details (Name
& Address) if
applicable

MMM

YYYY

Start Date
Post Graduation End Date
Year Of Passing

Page 2 of 8, Employment Application form V 02, wef - 11th May 2015

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY ,BHUBANESWAR

School/
College/
Institution
details (Name
& Address

University
Details (Name
& Address) if
applicable

EDUCATION DETAILS - contd. (Fill in CAPITAL Letters)

Qualification

Complete Name & Address of School / College / Institution and

Name of the University
*University name is mandatory where applicable(DO NOT ABBREVIATE)

Course Tenure

M M M Y Y Y Y
Start Date
Others - PhD,
Additional
Degrees

Percentage/
Grade Points

Registration /
Roll / Final
Year Seat
Number

Name of the
Degree
Awarded
(e.g.. B.com /
BA/ Mtech)

School/
College/
Institution
details (Name
& Address

End Date
Year Of Passing

University
Details (Name
& Address) if
applicable

State reasons for GAP in education, if any :

Preparing for 1 year for entrance after 12th.

Professional Training (includes in progress degrees) - please mention the details

*Have you worked for IBM earlier?

BUSINESS UNIT

Yes

DATE OF
JOINING

LOCATION

(DD-MMM-YYYY)

*Are you willing to relocate as part of

your employment with IBM?

Yes

No

If "YES", please provide following details:

LAST WORKING DAY

(DD-MMM-YYYY)

No

TYPE OF EMPLOYMENT
(Regular/FTH/Contractor)

MANAGER'S NAME

If yes, please indicate

your preferences

*Consistent with IBM's policy on workforce diversity and in order to accommodate employee's special
needs in the work environment, please indicate if you are physically challenged

Yes

No

** IBM Corporation is an Equal Employment Opportunity Employer

If yes, please provide description of disability and

accommodation / assistance required:

*Do you have any non-compete obligations or conflict situations or other restrictive clauses with any party
including any of your previous employers that prevent you from working for IBM India Private Limited?
Page 3 of 8, Employment Application form V 02, wef - 11th May 2015

EMPLOYEE NUMBER/
CONTRACTOR CODE

Yes

No

EMPLOYMENT HISTORY (FILL IN CAPITAL LETTERS)

Provide your last 3 (three) employment history. Also include information on self-employment. You can leave this page blank if you do not have prior work experience.

Serial
No
Organisation Name

01

02

03

Employment Type
(Permanent
/Contractual)

Organisation Name and address

*Most Recent

Tenure

Employee Number

Full Time / Part

Time

Start Date

Address along with PIN Code

End Date

Organisation Name

Start Date

Address along with PIN Code

End Date

Organisation Name

Start Date

Address along with PIN Code

End Date

Below is continuation of the above table. E.g. Continue to fill in details of "Serial No 1" (Above) in "Serial No 1-Continue" row below.
Serial
No

Designation

Reasons for Leaving

Reporting Manager's Name

and contact number)*

If Employment Type is Contractual, Please Provide Outsourcing Agency Name, Complete

Address and Contact Number
Organisation Name

Complete Address

Pin Code

Contact Number

Organisation Name

Complete Address

Pin Code

Contact Number

Organisation Name

Complete Address

Pin Code

Contact Number

01

02

03
*Current Reporting Manager will be contacted ONLY AFTER the candidate joins IBM
Total years of experience - (please do not include any
training or internship experience)
Page 4 of 8, Employment Application form V 02, wef - 11th May 2015

Years

Months

State GAP in
Employment if any:

009876533

OTHER DETAILS (Fill in CAPITAL Letters)

Current Annual Remuneration/ Cost to company
If you are related to IBM India Private Limited employees and/or Directors (sibling / spouse/ children/in law relationships), please provide names and relationship.
Name

Designation

Business Unit

*Have you ever been convicted? Are criminal charges pending against you?

Yes

No

If yes state the offence

Yes

*Have you worked for the Government, whether as a civilian employee or member of the military?

Relationship

No

All Candidates must indicate if they have worked for the Government, whether as a civilian employee or member of the military. If so, you must also indicate whether you had any responsibilities or were involved in
activities relating to IBM or an affiliated Company. You must also state whether you are aware of any legal restrictions on what work you may do for IBM or an affiliated Company, and if so, what those restrictions are.

Name of Government Organization and Department

Tenure
Job Responsibilities
Restrictions (if any)

DECLARATIONS
Source Declaration
1. If applicable, I hereby confirm that in my duties as a government employee, I have (or have had) no
matters involving IBM (in any capacity whatsoever), or if I do, that I have officially withdrawn from
participating in those matters while I am discussing potential employment with IBM. All details of any such
matters that I have been involved with, where IBM or any of its affiliates have been involved, are listed
above.
2. I confirm that the information provided by me in this application form is complete and accurate.
3. I understand that if any information provided by me with respect to my application for employment is
found to be untrue, inaccurate or misleading, IBM INDIA Private Limited may withdraw any offer of
employment made to me or terminate my employment (If I have already joined IBM India) without notice.
3. I understand that all the details provided in this application are subject to verification.
4. I hereby authorize IBM India Private Limited and its representatives (including reference check
agencies/third party vendors) to verify information provided in my application for employment and to
conduct enquiries as deemed necessary by the company.

By submitting the IBM Employee Referral name I confirm that the referrer is known to me personally or
professionally. This relationship may be a result on account of participation in various social networks which
are either formal (examples of formal networks are Linkedin, Facebook, Twitter, industry and competency
associations) or informal (examples of informal networks are former employment with the same company,
friends circle, alumni from same educational institution or study circles) .
I also confirm that the referrer has made me aware that by referring my candidature to IBM for an opportunity of
employment, he/she may be eligible to receive a referral bonus.

*Date
*Signature
Enter full name

ANSUMAN SATAPATHY

Page 5 of 8, Employment Application form V 02, wef - 11th May 2015

*Place

BHUBANESWAR

(DD-MMMYYYY)

17-09-15

BACKGROUND CHECK APPLICATION FORM - I

Last Name

SATAPATHY

Date of Birth

13/10/1993

Father's Name

ASHOK KUMAR SATAPATHY

Middle Name
Gender

Social Security # / National Insurance #

MALE

First Name
Nationality

IBM GOM Code / IBM Employee ID

ANSUMAN

INDIAN

M0986363

Passport No:

GBS-A36895453-17837906

Proof of name change attached if applicable

Yes

No

EDUCATION (Please mention only highest completed education as declared in Employment Application Form)
Name of Degree / Diploma

Also indicate Specialization of the Degree/

Diploma

B.TECH

*Name & Location of School/College/Institute

(also mention whether course attended is
Regular/correspondence)

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY,

GOTHAPATNA ,BHUBANESWAR REGULAR

Name & Location of university to which the

college/Institute is affiliated to

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY,

GOTHAPATNA ,BHUBANESWAR

Roll Number / Registration Number / Exam Seat

Number

ELECTRONICS AND ELECTRICAL ENGG. (EEE)

From MMM / YYYY

Dates
attended

Sep

2012

To MMM / YYYY
May

2016

From MMM / YYYY

Year of
passing

May

2016

B312007

Note : If you are a Fresher, please specify " NA" in all the fields below.
EMPLOYMENT RECORD: Starting with your present or most recent employer, please list last 3 employments in chronological order. When listing consulting or temporary assignments under "Employer", state the
name of the consulting or temporary agency that placed you at the client site

CURRENT / MOST
RECENT EMPLOYER
(Company Name)

NA

Complete Address

NA

From

NA

Job Title

To

NA

Employee ID :

Reason for
Leaving :

NA
NA

NA

Employment status (Permanent /Contractual)

NA

OUTSOURCING AGENCY DETAILS

Name

NA

Full Address

NA

PREVIOUS EMPLOYER
(PRIOR TO THE MOST
RECENT (Company Name)

NA

Pin code

NA

NA

------------------

Complete Address

NA

From

NA

Job Title

To

NA

Employee ID

Reason for
Leaving

NA

NA

Employment status (Permanent /Contractual)

NA

OUTSOURCING AGENCY DETAILS

Name

NA

Full Address

NA

Page 6 of 8, Employment Application form V 02, wef - 11th May 2015

Pin code

NA

BACKGROUND CHECK APPLICATION FORM - I contd.

SECOND PREVIOUS
EMPLOYER (Company
Name)
Complete Address

NA

NA

From

NA

Job Title

To

NA

Employee ID

Reason for
Leaving

NA
NA

NA

Employment status (Permanent /Contractual)

NA

OUTSOURCING AGENCY DETAILS

Name

NA

Full Address

NA

Pin code

NA

INFORMATION RELEASE AUTHORIZATION ( TO BE SIGNED BY THE CANDIDATE)

I certify that the statements made in this application are valid and complete to the best of my knowledge. I understand that false or misleading information may result in termination of employment.
If upon investigations, any of this information is found to be incomplete or inaccurate, I understand that I will be subject to dismissal at any time during my employment. I hereby authorize IBM and /or any of its
subsidaries or affiliates, and any persons or organizations acting on its behalf to verify the information presented on this application form and to procure an investigative report or consumer report for that purpose. I
hereby grant authority for the bearer of this letter to access or be provided with full details of my previous records.
In addition, please provide any other pertinent information requested by the individuals presenting this authority. I hereby release from liability all persons or I authorize to contact my present employer
I have read, understand and by my signature consent to these statements.

*Signature

ANSUMAN SATAPATHY

Page 7 of 8, Employment Application form V 02, wef - 11th May 2015

Enter full name

*Date
(DD-MMM-YYYY)

17-09-2015

*Place

BHUBANESWAR

BACKGROUND CHECK APPLICATION FORM - II

Last Name

SATAPATHY

Middle Name

Date of birth

13/10/1993

Gender

Father's Name

ASHOK KUMAR SATAPATHY

Passport Number

*Current Address

First Name

ANSUMAN

MALE

Nationality

INDIAN

M0986363

IBM GOM
Code / IBM
Employee ID

GBS-A36895453-17837906

Permanent Address (Please fill only if different from the current address)
D/23

L-202
* House/Flat No.
* Street (Cross &
Main)

* House/Flat No.
IIIT BOYS HOSTEL

* Street (Cross &

Main)

NALCO RESEARCH CENTRE

* Nearest
LandMark

* Nearest LandMark

* City

BHUBANESWAR

*PIN Code

751003

* State

*Country

* City

ODISHA

INDIA

*PIN Code

Point of Reference# along with Contact details

Name of the contact
person

ASHOK KUMAR SATAPATHY

Phone Number

NIT CAMPUS

CHILDREN PARK

ROURKELA

* State

769008

*Country

ODISHA

INDIA

Point of Reference# along with Contact details

Name of the
contact person

ABINASH MISHRA

Phone Number
9438575810

9668439164

* Present Address: Address where your are currently staying

** Permanent Address: Address where you are permanently residing, irrespective of Present address. This is typically your parents residence or an address in your home town.
# Reference: Could be your Parents, Spouse, Neighbours, Friends, Relatives, Room mate who stayed with you etc. or staying in close neighborhood.

INFORMATION RELEASE AUTHORIZATION ( TO BE SIGNED BY THE CANDIDATE)

I certify that the statements made in this application are valid and complete to the best of my knowledge. I understand that false or misleading information may result in termination of
employment. If upon investigations, any of this information is found to be incomplete or inaccurate, I understand that I will be subject to dismissal at any time during my employment. I hereby
authorize IBM and /or any of its subsidaries or affiliates, and any persons or organizations acting on its behalf to verify the information presented on this application form and to procure an
investigative report or consumer report for that purpose. I hereby grant authority for the bearer of this letter to access or be provided with full details of my previous records. In addition,
please provide any other pertinent information requested by the individuals presenting this authority. I hereby release from liability all persons or I authorize to contact my present employer.
I have read, understand and by my signature consent to these statements.

*Signature
Enter full name

ANSUMAN SATAPATHY

*Date
(DD-MMM-YYYY)

Page 8 of 8, Employment Application form V 02, wef - 11th May 2015

17-09-2015

*Place

BHUBANESWAR