EMPLOYEE QUESTIONNAIRE

BACKGROUND CHECK
FORM
Affix a copy of
your recent
passport
photograph here

INSTRUCTION: Note that the fields tagged "Required/*" are compulsory to be

filled with appropriate and full details. All other fields are necessary.
Personal Details

Surname D.O.B. (dd-mm-yyyy)

Other name(s)

Birth Place State

ofOri
gin

L.G.A. Maiden
Name [if
Email (personal) applicable]

Mobile Number ) Sex

[1](Required (Male/Female)

Mobile Number
[2](Required)

Current Designation Marital Status

Residential Address

Contact of person to be notified in case of any emergency

Name

Address

Phone Number(s) Relationshi

p

Educational Records

Name & Location of school

Entrance Year Exit Year

Certificate/Degree Obtained Matric No

Name & Location of School

 Entrance Year Exit Year

Certificate/Degree Obtained Matric No

Professional Certificates

Name of Professional Body

Membership No

Member
Status(Active/inactive)

Membership Start Date

Confidential (I)
Employment History
For Internal Use Only Page 1 of 4 BCI

EMPLOYEE QUESTIONNAIRE
BACKGROUND CHECK FORM

NOTE: The address of employer, employment/exit date (if applicable), name of

superior and contact details are very important details to input.
Current/Last Employer Type of Business

Address of
Current/Last
Employer(Required/*)

Location/Branch

Starting Designation
(Required/*)

Current/Last
Designation(Required/*)

Date Employed(Required/*) Exit

Date*

Office Telephone
No(s) (Required/*)

Supervisor’
Name(Required/*)

Supervisor’s Email

Seconded by An Name Of Agency

Agency(Yes/No)
Address of
Agency(Required/*)

Employment History

Name of Previous Type of Business

Employer

Address of Previous
Employer(Required/*)

Location/Branch

Starting
Designation(Required/*)

Current/Last
Designation(Required/*)

Date Employed(Required/*) Exit

Date*

Office Telephone
No(s) (Required/*)

Supervisor’
Name(Required/*)

Supervisor’s Email

Seconded by An Name Of Agency

Agency(Yes/No)

Confidential (I)
For Internal Use Only Page 2 of 4 BCI
EMPLOYEE QUESTIONNAIRE
BACKGROUND CHECK FORM
Address of Agency

Employment History

Name Of Previous Before Type of Business

Last Employer (Required/*)

Address of
Current/Last
Employer(Required/*)

Location/Branch

Starting
Designation(Required/*)
 Current/Last
Designation(Required/*)

Date Employed(Required/*) Exit

Date*

Office Telephone
No(s) (Required/*)

Supervisor’
Name(Required/*)

Supervisor’s Email

Seconded by An Name Of Agency

Agency(Yes/No)

Address of Agency

Guarantors Verification
(**** Those with Financial ability to Indemnify personnel’s allowed)

Guarantors Name

Residential
Address(Required/*)

Email Address(Required/*)

Office Address

Relationship

Phone Numbers(Required/*)

Guarantors Verification
(**** Those with Financial ability to Indemnify personnel’s allowed)

Referees: Name

Residential
Address(Required/*)

Email Address(Required/*)

Office Address

Relationship

Phone Numbers(Required/*)

Confidential (I)
For Internal Use Only Page 3 of 4 BCI
EMPLOYEE QUESTIONNAIRE
BACKGROUND CHECK FORM
NOTE
PLEASE ATTACHPHOTOCOPIES OF:
Educational Certificates and Credentials

I hereby acknowledge that the information supplied by me is true to the best of my knowledge. I
understand that any misinterpretation or omission may affect my application. I further authorize
the company to investigate all the above supplied information.
------------------------
- Date

---------------------------
- Signature

Confidential (I)
For Internal Use Only Page 4 of 4 BCI