Ver 1.

1 - Nov - 2014

ASSOCIATE INFORMATION & BACKGROUND CHECK FORM

Note: Please update all cells with correct and relevant data. The information provided in this document will form part of your
official records in the company and is subject to verification.

Affix your Photo Here

Date of Joining (dd/mm/yy)

Have you been employed with Polaris earlier ? If YES, Pls select the mode of engagement

Full Time Employee

Stipendiary Trainee

Associate ID
( To filled by HR )

Location of Joining

Direct
Contract

3rd party Contract

Place of Work
( To filled by HR )

Period of
Employment

Please provide your earlier

Polaris ID No.

From

TO

(DD/MM/YYYY)

Please provide your earlier Polaris

Email ID

Personal Details
First Name

Middle Name

Have you change your name in the past ? If yes,

please mention.

Last / Surname

Date of Birth

Your Father name

Gender ( )

(dd/mm/yy)

Male

Blood Group
Female

Personal Email ID

PAN No. / SSN or equivalent

Contact Details
Permanent Address :

Current Address :

Postal/Zip code :
City

Postal/Zip code :

State

City

State

Period of Stay
From (MM/YY)

Period of Stay
To (MM/YY)

From (MM/YY)

Residence Phone No.

Residence Phone No.

Your Mobile No.

Your Mobile No.

To (MM/YY)

Emergency Contact No.

Emergency Contact No.

Name & Relationship of emergency contact:

Name & Relationship of emergency contact:

Address History (List most recent first ) - Please provide addresses for the last 7 years
Period of Stay
From
To
( MM / YYYY )

( MM / YYYY )

Address

Country

Zip Code

Contact Number
with Relationship

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Ver 1.1 - Nov - 2014

Educational Qualification - Please attach copy of Degree and Final year mark sheet
Degree Awarded

Qualification

College / University Name &

Address

Year of Passing

ID/ Roll Number

Grade / Percentage

Masters

Bachelor

Diploma

12th
(Only for Freshers)

10th
(Only for Freshers)

Employment History - (List most recent first and other experience covering last 10 years prior to Joining Polaris)
Name of Previous Employer

Telephone No

Employee Code/No

Employment Period (DD/ MM/ YYYY)

From

Address of Employer

Manager's Name

Designation

Department

Manager's Contact No

To

Can we proceed with verification right

now?

Manager's Email ID
Yes

No

Reasons for leaving :

Permanent
Temporary
Contractual

Was this Position

Previous Employment History -

Agency Details (if temporary or contractual), provide details

Please submit a copy of your relieving letter/service certificate for each company

Name of Previous Employer (2)

Telephone No

Employment Period (DD/ MM/ YYYY)

From

Employee Code/No

Manager's Name

Address of Employer

Designation

Department

Manager's Contact No

To

Can we proceed with verification right

now?

Manager's Email ID
Yes

No

Reasons for leaving :

Was this Position

Permanent
Temporary
Contractual

Agency Details (if temporary or contractual), provide details

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Ver 1.1 - Nov - 2014

Previous Employment History -

Please submit a copy of your relieving letter/service certificate for each company

Name of Previous Employer (3)

Telephone No

Employee Code/No

Employment Period (DD/ MM/ YYYY)

From

Address of Employer

Designation

Department

Manager's Contact No

Manager's Name

To

Can we proceed with verification right

now?

Manager's Email ID
Yes

No

Reasons for leaving :

Permanent
Temporary
Contractual

Was this Position

Previous Employment History -

Agency Details (if temporary or contractual), provide details

Please submit a copy of your relieving letter/service certificate for each company

Name of Previous Employer (4)

Telephone No

Employee Code/No

Employment Period (DD/ MM/ YYYY)

From

Address of Employer

Designation

Department

Manager's Contact No

Manager's Name

To

Can we proceed with verification right

now?

Manager's Email ID
Yes

No

Reasons for leaving :

Permanent
Temporary
Contractual

Was this Position

Previous Employment History -

Agency Details (if temporary or contractual), provide details

Please submit a copy of your relieving letter/service certificate for each company

Name of Previous Employer (5)

Telephone No

Employee Code/No

Employment Period (DD/ MM/ YYYY)

From

Address of Employer

Designation

Department

Manager's Contact No

Manager's Name

To

Can we proceed with verification right

now?

Manager's Email ID
Yes

No

Reasons for leaving :

Permanent
Temporary
Contractual

Was this Position

Over all Work Experience in months

IT

Agency Details (if temporary or contractual), provide details

Non IT

Remarks if any-

Professional References
Name

Designation

Email Address

Contact Number

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Ver 1.1 - Nov - 2014

Do you have any relative/s working with Polaris? If yes, provide details
Name

Relationship

Emp ID

Department

Location

Remarks

Passport Details
Passport No.

Date of issue (dd/mm/yy)

Pls tick an appropriate option related to your Visa

status

Citizen

Legal right to work in the Country

Yes

Valid up to (dd/mm/yy)

Expat on Green
Card

Place of issue

Expat on Work Expat on Permanent Residency

Permit
permit

Mention the details of work permit :

Nationality

Country of issue

Any other Status

Work Permit valid till

No

Other Details
Have you suffered from any major illness or undergone any surgery in the past 3 years? If yes please give details

One of our Key Initiatives, SAMPADA (Special Appreciation and Mentoring Programme, Acknowledging Distinctly Abled people ) to us means empowerment to our
associates leading to an inclusive workplace. Please let us know if you have any special needs that require our attention.

Self Introduction : Please use free flowing text and tell us regarding your Hobbies, Interests, how you spend your free time and your professional alignments/memberships etc.

Declaration and Authorization

I confirm that today, ______ day______month_____________year is my date of joining in Polaris, and I am accepting the defined policies and processes in Polaris.
I also agree that my candidature with Polaris is valid only till I abide by the policies and processes of Polaris.
I give my consent and authorize PCSL (or a third party appointed by PCSL) to contact any former employee as indicated above and carry out all Background Checks not
restricted to education, employment, database search, address verification, criminal check, reference check deemed appropriate through this selection
procedure/continued employment. I authorize my former employers, agencies, educational institutes etc to release any information pertaining to my
employment/education and I release them from any liability in doing so.
I have not been charge sheeted for any offense under the CRPC and the IPC or any other criminal laws in India or of any of other country. I shall promptly notify Polaris
and the relevant stakeholders, if I am being charge sheeted for any offense now or any time during my tenure at Polaris.
I hereby declare that all information that I have provided in this form are true to the best of my knowledge, and that any misrepresentation of information by me will
disqualify my candidature and subsequent employment with Polaris Consulting & Services Limited (PCSL).

Place:

Name:__________________________

Date:

Signature:_______________________

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