Background Verification Form

BACKGROUND VERIFICATION FORM

Please fill in the details with utmost attention, as these shall be verified by the Company and/ or by its
authorized representatives. Please Affix Your
Passport Size
Photograph
All details are compulsory.

PERSONAL DETAILS
Name of Applicant: Surname S Middle Kumar First Sathish

Date of Birth (dd/mm/yy): 26/02/1979 Place of Birth: Thuraiyur, Tamil Nadu

Sex: MALE Nationality: Indian

Father’s Name: Sampath Kumar Passport No.: Z2682631

Home Phone: ?? Office Phone: ?? Mobile: 9884826279

RESIDENTIAL ADDRESSES
PERMANENT ADDRESS:
D18, 206,
PURVA WNDERMERE, BHAVANI AMMAN KOIL STREET,
PALLIKARANAI, CHENNAI - 600100

City: Chennai State: Tamil Nadu Pin Code: 600100 Phone No.: 9884826279
Duration of Stay: From (03/19) To
Nature of location: Rented Own Other (Specify)
CURRENT

CURRENT ADDRESS:
SAME AS ABOVE

City: Bangalore State: Karnataka Pin Code: ?? Phone No.: ??

Duration of Stay: From (11/19) To (Current)
Nature of location: Rented Own Other (Specify)

EDUCATION DETAILS

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NAME & ADDRESS

OF
DATES ATTENDED
ROLL
NAME & BOARD /
COURSE MARKS (%) NUMBER/
ADDRESS OF UNIVERSITY
ATTENDED CGPA REGISTRATION
QUALIFICATION SCHOOL / TO WHICH THE YEAR OF YEAR
(MORNING/ EVENING/ & NUMBER/
COLLEGE/ SCHOOL / CORRESPONDENCE) ENROLME PASSED
CLASS EXAM SEAT
INSTITUTE COLLEGE / NT (MM/YY) (MM/YY) NUMBER
INSTITUTE
IS AFFILIATED TO
Board of
JAYA Matric
Matriculation Full time
10TH
HSS, 78% 03/95 03/95 0066601
Examination, Tamil (Morning)
Thiruninravur
Nadu
Board of
JAYA Matric
Matriculation Full time
12TH HSS, 77% 03/97 03/97 2306697
Examination, Tamil (Morning)
Thiruninravur
Nadu

GRADUATION

DEGREE:

GKM
DISCIPLINE: Engineering University of Full time 69% 04/01 04/01 8709898
College, Madras (Morning)
Full Time Perungalathur
Part time
Distance
learning
course
POST
GRADUATION

DEGREE:

DISCIPLINE: Great Lakes Great Lakes

Distance 3.56 08/16 05/18 PGXPM16SAT
Institute Institute
Full Time
Part time
Distance
learning course

ANY OTHER
NA
DIPLOMA 1

ANY OTHER
NA
DIPLOMA 2

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EMPLOYMENT RECORD: Starting with your present or most recent employer, please list last 2 employments. When 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): Input Zero Employee Id: From (mm/yy): To (mm/yy):
Technologies 1346 10/19 Till Date
Street Address: A: 8th Floor, Employer’s Remuneration/Salary:
Umiya Business Bay-2, Phone No.:
Cessna Business Park, Kadubeesanahalli, 8892335813
Bangalore-560103
City: Bangalore State: Karnataka Country: INDIA Postal Code: 560103

Job Title: Head PMO Reason for leaving: NA

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

box) Name: Sumit
Full Time Title: VP- Customer Success & Strategy
Contract /Through Outsourcing Agency Phone No.: 8588824337
E-mail id: Sumit.mittal@inputzero.com
Outsourcing Agency Details: (Preferably official)
Name: HR Manager’s Details:
Address: NUTAN MEHTA
Name:
Tel No.:
Description of Duties: Phone No.: 8892335813
E-mail id:
(Preferably official) nutan.mehta@inputzero.com
Current Employment Authority Provided
Yes/No
yes
If No When

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EMPLOYER 2: Lava Employee Id: From (mm/yy): To (mm/yy):

International 53331 06/15 10/19
(Previous)
Street Address: A – 56 Sector -64 Employer’s Remuneration/Salary:
Noida – 201 301, India Phone No.:+ 91120 27L/A
4637333
City: Noida State: UP Country: INDIA Postal Code: 201301

Job Title: Head – Service Excellence Reason for leaving: For better career opportunities

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

box) Name: Sumit Mittal
Full Time Title: Head – Customer Service
Contract /Through Outsourcing Agency Phone No.: 8588824337
E-mail id: Sumit.mittal@lavainternational.in
Outsourcing Agency Details: (Preferably official)
Name: HR Manager’s Details:
Address:
Name: Prabhat Singh
Tel No.:
Description of Duties: Phone No.: 8588872305
Head India 2 service operations E-mail id: Prabhat.singh@lavainternational.in
(Preferably official)

EMPLOYER 3: Samsung India Electronics Pvt Employee Id: From (mm/yy): To (mm/yy):
Ltd 14574841 06/14 06/15
(Previous)
Street Address: No:24,Rajasekaran Street, Mylapore , Chennai -600004 Employer’s Remuneration/Salary:
Phone No.: 99400  15L/.A
71771
City: Chennai State: Tamil Nadu Country: India Postal Code: 600004

Job Title: Manager, Customer satisfaction Reason for leaving: for better career opportunities

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

box) Name: Srinivas Sekar
Full Time Title: BSM
Contract /Through Outsourcing Agency Phone No.: 9952961875
E-mail id: Srinivas.ss@samsung.com
Outsourcing Agency Details: (Preferably official)
Name: HR Manager’s Details:
Address:
Name: Reena Vijaanand
Tel No.:
Description of Duties: Phone No.: 99400  71771
Handling Branch Admin operations E-mail id: Reena.v@samsung.com
(Preferably official)

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EMPLOYER 4: Reliance Retail Employee Id: From (mm/yy): To (mm/yy):

(Previous) 59002057 10/12 06/14
Street Address: No.89, Radhakrishnan Salai, Mylapore, Chennai - 600004 Employer’s Remuneration/Salary:
Phone No.: 044 11.26Lcs
43320000
City: Chennai State: TamilNadu Country: INDIA Postal Code: 600004

Job Title: Manager – after sales services Reason for leaving: For better career prospectives

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

box) Name: Ramesh
Full Time Title: RSM- CS
Contract /Through Outsourcing Agency Phone No.: 9591045008
E-mail id: Ramesh.s@ril.com
Outsourcing Agency Details: (Preferably official)
Name: HR Manager’s Details:
Address:
Name: Sajith S
Tel No.:
Description of Duties: Phone No.: 9004281767
Handling Tn & KL service ResQ operations E-mail id: sajith.satheesan@ril.com
(Preferably official)

Professional References

Name Contact No. Company Designation Relationship with the

referee
1. S.Bala Murali 9003026717 Hypertherm Lead Engineer Friend
6369789361 RPG Group VP – Sales Head EX- Boss
2. Prakash
Andrew

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