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I -: EMPLOYMENT FORM :-

I FORM NO.:2 - 400 067.

PHONENo.:-28609011 (4L1NESI.FAX:-28609734 PLOT NO. 134 AlB, FIRST FLOOR, GOVT. INDUSTRIAL
ESTATE, KANDIVLI (WEST), MUMBAI

1) To be filled in by Applicant's own handwriting. 2) Tick (...;) appropriate box as applicable. POST APPLIED FOR :-

AFFIX RECENT PHOTOGRAPH

1. PERSONAL HISTORY :a) NAME :- Mr. IMs. :-

(Surname)

(First Name)

(Father's/Husband'sName)

b) PermanentAddress:-

c) Contact Address :-

(1\ Dhone No. (Resi.) :e) Date of birth :f) Marituaf Status:Married ( )

(C&!I)

Other AGE :- (Next Birthday) :-

Single ( )
Name

Other (Specify)

( )

2. FAMILYDETAILS :Relationship Father Mother Age Qualification Occupation h

8
Brother's

Sister's

Husband Mlife Children

2.
...

-23. HEALTH INFORMATION :a) How would you rate your present Health? b) In your rate your present state of health would you consider yourself incapaciated for any Job I activities? c) Do you wear glasses? d) Height :e) Weight :4. HOME TOWN :5. NATIONALlTY:6. RELIGION :- . 7. PROVIDENT FUND MEMBERSHIP

~ORM NO. :21 : Poor ( ) : Yes ( )


: Yes ( ) Fair () No ( ) No ( ) Good ( )

If yes, for reading only or always?

: Yes ( ) : Number :-. No ( ) : Yes ( ) : Number :-. No ( ) : Yes ( ) : Number :-. iJo ( )

8. FAMILYPENSION FUND :-

9. E.S.I. .10. LANGUAGES:MOTHER TOUNGUE: OTHER: 11 QUALIFICA T~~NS :Examination Passed I Degree or Diploma Obtained

Year of Passing

Class of

IPrincipal Sub.
I .

School/CollegE
Institute

Universi

Degree IDiploma

Studied

i\

e
Institution

12 SHORT TERM & PART-TIME SPECIALISED COURSES I TRAINING PROGRAMES ATTENDED. Place'" Year Period of Attendence Description of Cource Certificate Awarded

OJ -.

-3Have you ever been prosecuted in a Criminal Court ? If so, give details and results of the preosucution ? 14. REFERENCES :Give two references (other than relatives). Please ensure that they have known you well personally & professionally. We shall writing to each one of them for a reference.

I FORM NO..:~ I

'13. LEAGALACTION (if any) :-

Name

Designation

Address

Period for which he/she knows you

capacity in whiCh he/she knows you

8
l1. 1 i~einformation given by me in this form is true to the best of my knowledge and belief.

2. Ifany informationis found false, I myselfshall be held res )onsiblefor any legal and other consequences.
My services are also liable to be terminated without.notic!!.

Date :Place :Signature


-: FOR OFFICE USE ONLY :1. Interviewed on :2. Interviewed by :a) Name: b) Designation:c) Signature :3. Selection Approved/Rejected by :4. Salary Offered :5. Designation :6. Dept. I Place of Work :-

Remarks :-

-------

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