BLUE CROSS LABORATORIES PVT LTD.

Peninsula Chambers, Ganpat rao Kadam Marg,

Lower Parel, Mumbai 400 013.

EMPLOYMENT APPLICATION FORM

Please paste a
passport sized
Applied Date : 15 02 2025 photograph

Post Applied for : SE

Location : ( EXCEL )

A) PERSONALDETAILS
Name ofT Applicant : Mr./Ms.,
First Name Middle Name Surname

Date of Birth : Age: 2023 Gender: Male

Birth Place : DHOLPUR DHOLPUR Blood Group: positive (O+)

Present Address :

City: Pin Code: State: RAJASTHAN Tel Nos. Res: Mobile:

Period of stay at present address:

Permanent Address:

City: Pin Code: Personal email: Nationality: INDIAN

PAN No.: Aadhaar No.: UAN No.:

Do you hold a driving license for two-wheeler or car? YES Have you ever been subjected to any legal proceedings? NO

Emergency contact details:

Name Relation Address Tel. No.

BAIJNATH TYAGI FATHER

Have you appeared for any interview in Blue Cross in the past? YES If Yes, for which position ABM

Language Speak Read Write

HINDI YES YES YES

ENGLISH YES YES YES

B) HEALTH DETAILS

Personal Health: Last Sickness: (Date/ Period) Type of Sickness

Do you have any Chronic Disorders like Diabetes ,Hypertension, any other disorders, please specify?
NO

5.4 65 KG
Height: ______ Weight: ______ Vision (If using glasses, specify no.) : _________________________________________________
 BLUE CROSS LABORATORIES PVT LTD.
Peninsula Chambers, Ganpat rao Kadam Marg,
Lower Parel, Mumbai 400 013.

EMPLOYMENT APPLICATION FORM

C) FAMILY DETAILS Son Daughte Others

Marital Status : Single/Married/Divorced/Widowed No. of Dependents :

Date of Marriage: __________________

Family Background Date of Birth Occupation

DD/MM/YY Company Name / Designation

Husband's/ Wife's Name : ___________________________________

Childs Name :_____________________________________________ Sex: M / F____________________

Childs Name :_____________________________________________ Sex: M / F_____________________

Father's Name:____________________________________________

Mother's Name: ___________________________________________

Brother's Name:___________________________________________

Brother's Name: ___________________________________________

Sister's Name:_____________________________________________

Sister's Name:_____________________________________________
Parents' General Health :

Good
Father's :____________________ GOOD
Mother's : ___________________

D) EDUCATIONAL QUALIFICATIONS: (Starting from 10th Std)

Month & Year %
Education Stream/Course Name of passing School / College Board/University Marks
SSC/ X th Std
ALL SUB.
HSC / Xll th Std

Graduation

Post-Grad.

Others

Achievements Failures

1)______________________________________________ 1)______________________________________________

2)______________________________________________ 2)______________________________________________

3)______________________________________________ 3)______________________________________________
BASIC KNOWLEDGE
COMPUTER SKILLS : _________________________________________________________________________________________

EXTRA CURRICULAR ACTIVITIES:

Sports: ______________________________________________ Hobbies: ______________________________________________

Other Interests:_____________________________________________________________________________________________
 BLUE CROSS LABORATORIES PVT LTD.
Peninsula Chambers, Ganpat rao Kadam Marg,
Lower Parel, Mumbai 400 013.

EMPLOYMENT APPLICATION FORM

E) WORK EXPERIENCE :
Particulars 1st Job 2nd Job Last Job Current Job
Period of From : From : From : From :
Employment
To. : To. : To. : To. :
Company
Name&
Address
Designation
Place of
Posting

Reporting to
Last CTC (Rs)
Reasons for
leaving

If number of Companies are more than above, please name them below:

1) _________________________________ 2) __________________________________ 3)________________________________

WHAT INTERESTS YOU IN JOINING BLUE CROSS? (1} _______________________________________________________________
2)___________________________________________________ 3)___________________________________________________
DO YOU KNOW ANYONE IN BLUE CROSS ? ____________________________Relationship_________________________________
YOUR CAREER OBJECTIVES: IN NEXT 3 YRS ___________________________ IN NEXT 6 YRS ________________________________

Name of three professional superiors in the last 5 years (REFERENCES)

Name Place Tel . No./Mobile No. Profession / Business

Two important mentors so far, if any, and lessons learnt :

Name Place Tel . No./Mobile No. Profession / Business

Name of three good personal friends & their occupation

1)___________________________________________________________________________________________

2)___________________________________________________________________________________________

3)___________________________________________________________________________________________

Present Key Personal (Family) Responsibilities:

TAKE CARE OF MY PARENTS

1)___________________________________________________________________________________________

TAKE CARE OF MY FAMILY

2)___________________________________________________________________________________________

3)___________________________________________________________________________________________
 BLUE CROSS LABORATORIES PVT LTD.
Peninsula Chambers, Ganpat rao Kadam Marg,
Lower Parel, Mumbai 400 013.

EMPLOYMENT APPLICATION FORM

F ) REMUNERATION DETAILS:
Details of your present remuneration as on Date ________ month_______year_________. Please do not include benefits for

which you are not presently eligible. Enclose latest salary slip/certificate in support.

a) MONTHLY (In Rs.) b) ANNUAL (In Rs.)

Basic Salary Annual Bonus / Ex-Gratia
Monthly Allowances
LTA
Incentives
Others (specify) Medical
Gross Salary 0
Total CTC (ax12+b}
Net Salary 0

C) OTHER BENEFITS YES/NO d)LEAVE (DAYS)

Provident Fund Privilege leave
Monthly Allowances Casual leave
Incentives Sick leave
Others (specify) Any other leave (specify)
Leave encashment (YES/NO)

JOINING TIME REQUIRED:___________________________SALARY EXPECTED (GROSS P.A.)₹_____________________

G ) ADDITIONAL INFORMATION (ONLY FOR FIELD PERSONNEL)

Last Job Current/ Present Job
Company Name &
Division
Dr. Calls / Day

Chemist Calls/ Day

Key Dr. specialists

covered
Specific Training
Received
Daily Allowances
HQ

Ex-HQ

Outstation

Other Expenses

H ) PREFERRED LOCATION
(Give Priorities) 1.______________________________ 2__________________________ 3._____________________________

What special qualities/skills you think you have which make you suitable for the post applied for :

1.________________________________________________
HARD WORKING 2. _____________________________________________________
POSITIVE THINKING

3.________________________________________________
HONESTY 4.______________________________________________________
TIME MANAGEMENT

I) DECLARATION : I hereby declare that the particulars stated above are true. Any false statements made herein shall render my
services liable for termination without notice
13/02/2025
DATE:____________________

Signature