BACKGROUND CHECK FORM

Please fill in the details with utmost attention, as these shall be verified by the Company and/or by its
authorized representatives.

All details are compulsory.

PERSONAL DETAILS
Name of Applicant:

(First) (Middle) (Last)

Date of Birth (dd-mm-yyyy): Place of Birth:

Gender: Nationality:

Father’s Name:

Pan Number:

Home Phone: Office Phone: Mobile:

RESIDENTIAL ADDRESS
CURRENT ADDRESS:

City: State: Pin Code: Phone No.:

Duration of Stay: From (mm/yy) To (mm/yy) Nature of location: Rented Own Other
(Specify)

Copyright 2021 DigiVerifi Private Limited. All rights reserved. No part of this publication may be reproduced, photocopied, stored on
a retrieval system, or transmitted without the express prior consent of DigiVerifi Private Limited.
 EDUCATION DETAILS
NAME & DATES ATTENDED
ADDRESS OF ROLL
BOARD / NUMBER/
NAME & COURSE MARKS
UNIVERSITY YEAR OF YEAR REGISTRAT
QUALIFICATION ADDRESS OF ATTENDED (%)
TO WHICH THE ENROLMENT PASSED ION
SCHOOL / (MORNING/ CGPA
SCHOOL / (MM/YY) (MM/YY) NUMBER/
COLLEGE/ EVENING/ &
COLLEGE / CORRESPONDENCE) EXAM
INSTITUTE CLASS
INSTITUTE SEAT
IS AFFILIATED NUMBER
TO

HIGHEST
EDUCATION
DETAILS

Copyright 2021 DigiVerifi Private Limited. All rights reserved. No part of this publication may be reproduced, photocopied, stored on
a retrieval system, or transmitted without the express prior consent of DigiVerifi Private Limited.
EMPLOYMENT RECORD: Starting with your present or most recent employer, please list last 5 years employments (if
applicable). While listing consulting or temporary assignments, under “Employer”, state the name of the consulting
or temporary agency that placed you at the client site. Complete and accurate dates (month/year) must be
provided.
EMPLOYER 1 (Current): Employee Id: From (mm/yyyy): To (mm/yyyy):

Street Address: Employer’s Phone Remuneration/Salary:

No.:

Annual Monthly
City: State: Country: Postal Code:

Job Title: Reason for leaving:

Form 16 Attached: Yes/No (if No, specify

the reason and share the bank statement
of this tenure)

Note: Form 16 submission is mandate

EPFO Details Available: Yes/No
UAN Number:
PF Number:

Employment Status: (Please check the Supervisor’s Details:

relevant box) Name:
Full Time Title:
Contract /Through Outsourcing Agency Phone No.:
E-mail id:
Outsourcing Agency Details: (Preferably
Name: official)
Address: HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably
official)
Can your current employer be contacted?
Yes/No
(If not, please provide date)

Copyright 2021 DigiVerifi Private Limited. All rights reserved. No part of this publication may be reproduced, photocopied, stored on
a retrieval system, or transmitted without the express prior consent of DigiVerifi Private Limited.
EMPLOYER 2 (Previous): Employee Id: From (mm/yyyy): To (mm/yyyy):

Street Address: Employer’s Phone Remuneration/Salary:

No.:

Annual Monthly
City: State: Country: Postal Code:

Job Title: Reason for leaving:

Form 16 Attached: Yes/No (if No, specify

the reason and share the bank statement
of this tenure)

Note: Form 16 submission is mandate

EPFO Details Available: Yes/No
UAN Number:
PF Number:
Employment Status: (Please check the Supervisor’s Details:
relevant box) Name:
Full Time Title:
Contract /Through Outsourcing Agency Phone No.:
E-mail id:
Outsourcing Agency Details: (Preferably
Name: official)
Address: HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably
official)

Copyright 2021 DigiVerifi Private Limited. All rights reserved. No part of this publication may be reproduced, photocopied, stored on
a retrieval system, or transmitted without the express prior consent of DigiVerifi Private Limited.
EMPLOYER 3 (Previous): Employee Id: From (mm/yyyy): To (mm/yyyy):

Street Address: Employer’s Phone Remuneration/Salary:

No.:

Annual Monthly
City: State: Country: Postal Code:

Job Title: Reason for leaving:

Form 16 Attached: Yes/No (if No, specify

the reason and share the bank statement
of this tenure)

Note: Form 16 submission is mandate

EPFO Details Available: Yes/No
UAN Number:
PF Number:
Employment Status: (Please check the Supervisor’s Details:
relevant box) Name:
Full Time Title:
Contract /Through Outsourcing Agency Phone No.:
E-mail id:
Outsourcing Agency Details: (Preferably
Name: official)
Address: HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably
official)

Copyright 2021 DigiVerifi Private Limited. All rights reserved. No part of this publication may be reproduced, photocopied, stored on
a retrieval system, or transmitted without the express prior consent of DigiVerifi Private Limited.
EMPLOYER 4 (Previous): Employee Id: From (mm/yyyy): To (mm/yyyy):

Street Address: Employer’s Phone Remuneration/Salary:

No.:

Annual Monthly
City: State: Country: Postal Code:

Job Title: Reason for leaving:

Form 16 Attached: Yes/No (if No, specify

the reason and share the bank statement
of this tenure)

Note: Form 16 submission is mandate

EPFO Details Available: Yes/No
UAN Number:
PF Number:
Employment Status: (Please check the Supervisor’s Details:
relevant box) Name:
Full Time Title:
Contract /Through Outsourcing Agency Phone No.:
E-mail id:
Outsourcing Agency Details: (Preferably
Name: official)
Address: HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably
official)

Copyright 2021 DigiVerifi Private Limited. All rights reserved. No part of this publication may be reproduced, photocopied, stored on
a retrieval system, or transmitted without the express prior consent of DigiVerifi Private Limited.
EMPLOYER 5 (Previous): Employee Id: From (mm/yyyy): To (mm/yyyy):

Street Address: Employer’s Phone Remuneration/Salary:

No.:

Annual Monthly
City: State: Country: Postal Code:

Job Title: Reason for leaving:

Form 16 Attached: Yes/No (if No, specify

the reason and share the bank statement
of this tenure)

Note: Form 16 submission is mandate

EPFO Details Available: Yes/No
UAN Number:
PF Number:
Employment Status: (Please check the Supervisor’s Details:
relevant box) Name:
Full Time Title:
Contract /Through Outsourcing Agency Phone No.:
E-mail id:
Outsourcing Agency Details: (Preferably
Name: official)
Address: HR Manager’s Details:
Tel No.: Name:
Description of Duties: Phone No.:
E-mail id:
(Preferably
official)

DOCUMENTS REQUIRED (COMPULSORY) ATTACHED YES / NO

Copy of Relevant Education Certificates
Current Address Proof
Please note: Your name should be mentioned on the
address proof.
Accepted address proofs: MTNL Bill / Electricity
Bill/ Copy of Rent Agreement/ Passport/ Voter Id/
Driving License.
Copy of all past Employment Appointment & Relieving
Letters/Salary Slips with employee code
Form 16 of all past employment

Copy of Identity Proof

Copyright 2021 DigiVerifi Private Limited. All rights reserved. No part of this publication may be reproduced, photocopied, stored on
a retrieval system, or transmitted without the express prior consent of DigiVerifi Private Limited.