Strictly Confidential

Application For Employment

Please ensure that the details provided on this form are correct and complete in all respects, as this information will be used for all official
requirements. Mandatory fields are marked with * and wherever not application, put "NA". Please fill the details in BLOCK Letters

Personal Information
First Name *
Middle Name
Last Name (Surname) *
Gender
Form of Address / Title (Mr /Ms /Mrs /Miss) * PHOTOGRAPH
Academic Title (Dr, Prof, etc.)
Birth Date (DD.MM.YYYY) *
Birth Place (City / Town)
State of Birth
Country of Birth
Nationality by Birth *
2nd Nationality / Current Nationality, if any
Marital Status
Permanent Account Number (PAN) *
Aadhaar Number *
SSN (Social Security No.), if applicable
Blood Group
Personal Email Id
Former / Maiden Names (if applicable)
Date(s) of Name Change

Permanent Address
C/o
Address Line 1
Address Line 2
Town/City *
Postal Code
District
State
Country *
Telephone Number (Landline)
Mobile Phone *

Current Mailing Address

C/o
Address Line 1
Address Line 2
Town/City *
Postal Code
District
State
Country *
Telephone Number (Landline)
Mobile Phone *

Emergency Contact Details

Name of Emergency Contact
Relationship
Address Line 1
Address Line 2
Town/City *
Postal Code
District
State
Country *
Telephone Number (Landline)
Mobile Phone *
 Strictly Confidential

Application For Employment

Family Member / Dependents Data

Father Mother
First Name *
Last Name *
Gender *
Date of Birth (DD.MM.YYYY) *
Nationality
Occupation
Organization

Spouse Child 1
First Name *
Last Name *
Gender *
Date of Birth (DD.MM.YYYY) *
Nationality
Occupation
Organization

Child 2 Child 3
First Name *
Last Name *
Gender *
Date of Birth (DD.MM.YYYY) *
Nationality
Occupation
Organization

Educational / Professional Qualifications

 Please provide details of all educational & professional qualification attained starting with your first qualification
 Only degree/diploma equivalent qualifications or higher are to be provided

Qualification # 1 - Class X Qualification # 1 - Class XII

Qualification / Degree Level *
Education Type / Area of Specialization *
Mode (Full Time/Part Time/Distance)
Name of University/Institute/College *
Address of the University/Institute/College

Year of Passing (DD.MM.YYYY) *

Class / Division

Qualification # 3 Qualification # 4
Qualification / Degree Level *
Education Type / Area of Specialization *
Mode (Full Time/Part Time/Distance)
Name of University/Institute/College *
Address of the University/Institute/College

Year of Passing (DD.MM.YYYY) *

Class / Division
 Strictly Confidential

Application For Employment

Work History

 Please provide complete employment history prior to GSK

 Ensure that you are descriptive wherever necessary; e.g. if the company has closed/ceased operations/moved location, do mention it
 Start with your most recent/current employer, followed by details of the employment preceding that

Record # 1 Record # 2
Name of Employer *
Address

City *
Country *
Start date of employment (DD.MM.YYYY) *
End date of employment (DD.MM.YYYY) *
Job Title / Last Designation *
Type of Employment
If Temporary or Contractual, please
provide name of agency
Reason for Leaving
Last Salary (CTC) Drawn / Current CTC

Record # 3 Record # 4
Name of Employer *
Address

City *
Country *
Start date of Employment (DD.MM.YYYY) *
End date of Employment (DD.MM.YYYY) *
Job Title / Last Designation *
Type of Employment
If Temporary or Contractual, please
provide name of agency
Reason for Leaving
Last Salary Drawn / Current CTC

Gaps in Employment
Please provide details of all gaps of 1 month or more that you may have between your past employments or between leaving the last
employment and joining GSK Group Companies.
Gap From (DD.MM.YYYY)
Gap To (DD.MM.YYYY)
Gap Period (in months)
Reason

Past Employment(s) with GSK Group of Companies, if any

Department Designation From To Reasons for Leaving

Significant Training Programmes attended

Name of the Training Programme Institution / Place of Training From To Training Areas Covered

Languages Known
Language Speak Read Write
 Strictly Confidential

Application For Employment

References
 Please provide details of 2 references that may be contacted to obtain feedback.
 Ensure that the references provided are not friends, members of your family or are current employees of GSK Group of Companies
Reference # 1 Reference # 2
Name
Contact No. *
Email Id *
Occupation (Provide details)
Relationship with the Referee
Years you have known the Referee

Other Information
Are you currently engaged in any other business either as a proprietor, partner, officer, director,
trustee, employee, agent, retainer, contractor, consultant, free lancer or otherwise. If yes, please
give details.
Yes / No

Have you ever been dismissed from the services of any previous employer(s)? If yes, please give
details.
Yes / No

Have you ever been convicted in a court of law or of a criminal offence? If yes, please give details
and status of prosecutions against you.
Yes / No

Have you ever had any civil judgments made against you? If yes, please give details.

Yes / No

Have you any obligations towards the Armed Forces e.g. as a Reservist? If yes, please give details.

Yes / No

Do you have any of your relatives or friends employed in GSK Group of Companies? If yes, please
give details.
Yes / No

Do you live with or are you related to anyone who works for a Company that makes products like
ours such a Pharmaceuticals? If yes, please give details.
Yes / No

Have you been interviewed previously for employment in this Company? If yes, please give details.

Yes / No

Declaration / Authorization

“I hereby declare that the information I have given is true and correct to the best of my knowledge. I understand that a
misrepresentation or omission of facts called for herein shall be sufficient cause for cancellation of consideration for employment or
dismissal from the Company’s service if I have been employed, without liability to the Company.

I hereby declare that, to the best of my knowledge there is nothing on grounds of health which would preclude me from meeting the
conditions of employment and performing my duties in a consistent and satisfactory manner. I also declare that I am fully competent,
fully capable and available to undertake the duties of the post.

I hereby declare that I have not been convicted of any crime & no criminal proceedings have been initiated and remain pending against
me under any law in the Country. I confirm that should I be convicted of a criminal offence at anytime during my employment with GSK,
I would stand liable to be terminated from the services of Company with immediate effect.

Applicant's Name Signature Date & Place