Employment Application

Position Applied For

Personal Details

Surname

First Name

Middle Name

Marital Status

Gender Nationality Religion

Date Place of Birth State Contact: Mobile No:

Spouse’s name Spouse’s date of birth

Father’s name Father’s date of birth

Mother’s name Mother’s date of birth

Children’s Details Name Date of Birth Gender

Present Address Permanent Address

Pin Code & State Pin Code & State

Valid Passport number Issued on Issued at Valid Visa (For Countries)

Languages Known Language Read Write Speak

English

Hobbies:

Blood Group: Emergency Contact No:

In case you are selected – Is there a requirement of a Corporate No. (Y/N)

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Academics Category – UG (Undergraduate), G (Graduate), PG (Post Graduate) D - Doctorate

From Date To Date Name of the Degree & Specialization Institute & Location Board/ Type Results
(as applicable Affliation Full Time/Distance

Gap in Academics

In case there has been a Gap in Education tenure, kindly indicate :Yes/No -
If Yes , Provide Details:

From Date To Date Reason of Gap

Career In reverse chronological order – Start with your present employment

Total experience (In years and months):

From Date To Date Organization / Location Type of industry/Self Employed Last Designation Reasons for leaving

Gap in Career

In case there have been periods of unemployment / self-employment, kindly indicate:Yes/No -

From Date To Date Reason of Gap

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Responsibilities & Achievements In Present Employment

Key responsibilities Major achievements (Personal / Professional)

About Your Present Employment

Annual Turnover Employee Strength Number of Direct reports Gross Salary p.a. (Starting) Gross Salary p.a. Reporting to
. (Current)

Extra-Curricular Activities

Sl. Nature of Activity Level of Participation Year Highlights

Any other information, you would like to furnish…

If you are related to any of the employees of PCBL, please furnish details

Name Designation Location Nature of relationship

Have you been interviewed earlier by us / our associate companies?

If Yes, Position interviewed for Date / Period of interview

Place of interview Interviewer

How soon would you be free to take up the new assignment, if offered?

What is your current remuneration per annum?

What remuneration do you expect to receive per annum?

Do you have any locational preference?

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Current Remuneration Details All figures in Indian Rupees

Annual earnings Retirals (Annualized) Other Perquisites (Annualized)

Basic Salary Provident Fund Club membership

Dearness Allowance Gratuity Leave encashment

City Compensatory Allowance Superannuation Medical reimbursements

Special Allowance Perquisites p.a. Medical insurance

HRA LTA Telephone (Residence)

Conveyance Allowance Bonus / Ex-gratia Others

Others

Leave (Per Annum) Privilege Leave

Casual Leave

Sick Leave

Gross total per annum Any other, please specify

References Details of two persons other than your relatives

Name Designation Organization Telephone E-Mail

Declaration I hereby declare that I am / I am not related to any of the Directors of the Company as his partner or his relative as defined under Section 6 of the Companies Act, 1956.

I hereby declare that the information given is true to the best of my knowledge and will form the basis of the contract of employment if I am employed by Phillips Carbon Black. If at a later date if is found that any information furnished herein is untrue

or incorrect in any material respect, the Company will have the right to terminate my service without notice or salary in lieu thereof

Place Date Signature