Confidential

Job Application Form

Photo

Position Applied For:

Personal Information:

Name: Highest Degree:

Residential Address
(Current):

Residential Address
(Permanent):

Home Telephone: Office Telephone: Mobile: Post Code:

Emergency Contact Details (Family Member Required): Name, Address and Telepho

Email id :

Date of Birth: Place of Birth： Nationality:

ID Card / PAN Card

Passport Number: Blood Type:
Number:

Family Status:

Marital Status:

Name of Family Member Relation Date of Birth / Age Education Occupation Company Name & Position Title

Father

Mother

Spouse

Kids

Sibblings

Annexure 3-5: (T.A Policy 3 – Recruitment and Selection Policy & Process, Asia Pacific)
Education Background:

Degree Universtity / Institution Location Year Score/ Rank

Language: English: Read Write Speak (please tick ( √ ) whichever applicable)

Other (please provide):

Other Skills:

Employment Details:

Current Employer: Position Title:

Department / Function: Joining Date: Total years of Experience:

Current CTC
Expected CTC Notice period

Previous Employment details:

Date of Date of
Joining Separation Company Position Title Salary Exit Reason

Current Status □ Out of Service □ In Service

Reference Check:

Please advise if you are in agreement with reference check:

If yes, please provide the contact information of reference persons (Direct supervisor and HR Manager in your previous company)

If no, please advise the reason:

Name Position Title Company Address Telephone / Email

Annexure 3-5: (T.A Policy 3 – Recruitment and Selection Policy & Process, Asia Pacific)
 Questions Yes No

Have you ever been dismissed from any employment before?

Have you ever got involved in any illegal activities?

Have you ever signed any kind of non-compete agreement?

How did you get the recruitment information？ □ Internal Recommendation

□ Magazine

□ Internet (Please advise the website)

□ Others

Do you have any relative (blood or by marriage) or other member of your household
who works at Diebold or any of its subsidiaries?

Are you related to or do you have a close personal relationship with any government
officials(Note1), including but not limited to employees of government owned
organizations/entities?

Are you currently a government official or employee of a government owned

organization/entity?

Do you have any friends / relatives working with Vendors Associated with Diebold?
Please advise Vendor details and your relationship with the Vendor
Note1: The term government official includes officers and employees of government agencies, government departments (including
federal, regional, state, local, or foreign government organizations or entities), and government instrumentalities, and public
international organizations (e.g. the United Nations, the World Bank, or the International Monetary Fund), and anyone acting in an
official capacity on behalf of these entities. The term government instrumentality includes government owned or controlled and
partially-owned or partially-controlled companies and other commercial enterprises. Examples of government instrumentalities are
state-owned banks, state-owned insurance companies, or state-owned airlines.

Declaration:
I, <Name of applicant> __________________________ hereby certify that, i have read & understood this form and the
requirements stated therein. The information updated by me in this application form is true and correct. i understand that,
any of my false statements or dishonest answers to any questions may be sufficient cause for immediate termination of my
employment with Diebold and / or any legal proceedings, as deemed fit. I also authorize Diebold to conduct Background
checks and / or Reference checks for my statements made in this form or any documents that i have submitted to Diebold.

Date: Applicant's Signature:

Annexure 3-5: (T.A Policy 3 – Recruitment and Selection Policy & Process, Asia Pacific)