Employee Verification Form

Applicant No/ Employee ID / Client Reference Number / Designation / Entity
2269667 / Delivery
Module Lead / GGIT o
GGIT – USA o
KFIT o
DSC o
JPMC New o

¬  Please provide complete and correct information.

¬  All fields are mandatory.

¬  Please do not use short forms / abbreviations.

¬  Please refer to page 12 for documents & information required

Personal Details

Title (Mr. / Mrs. / Ms.)
Last name / Mr.
First name / Middle name
Pandey / Ashutosh / Kumar
Nationality / Indian
Date of Birth
(yy/mm/dd) / 80/03/01
Place of Birth / Chapra, Bihar
US Social Security Number (If applicable)
Gender: Male / Marital Status: Married
Contact Telephone No. / Office Tele No. / Mobile / Pager / Email Address
9958214943 / 9958214943 / 9958214943 /

Family Details

Name of Father: (Last name) / (First name) / (Middle name)
Pandey
/ Shila / Nath
Address: / At-Raja Chapra, PO-Badlu tola, PS-Chapra Mufassil, Dist- Saran, Pin - 8414114 / Contact Telephone No.
(09939714968 )
Next of Kin: (Last name) / (First name) / (Middle name)
Pandey / Priti
Address: / A/3, 203,Gayatri Residency,Medatiya Nagar,Opp - Seven Square Academy, Deepak hospital lane, Mira Road East, Thane-401107 / Contact Telephone No.( 9015843903 )

Passport Details

Do you have a valid Passport? /

If applied for one

File number in passport application:
Yes o No ü / TH1060825672017
Passport number:
Name as in passport
Date of Birth (yyyy/mm/dd)
Place of residence (if shown)
Date of issue (yyyy/mm/dd)
Place of issue
Expiry date (yyyy/mm/dd)

Identity Details

Primary Documents to be attached (Any two)
Passport / Number: Date of expiry:
Driving License / Number: Date of expiry:
PAN Card / Number: AZCPP2977N Place of issue: Applied in Delhi and it was delivered at my permanent address Chapra, Bihar
Election ID card / Number: IPS2241008 Place of issue: Delhi
Secondary Documents to be attached if primary documents are not available
Marriage Certificate / Number: Place of issue:
Secondary School Leaving Certification / Seat Number: Year of passing
Birth Certificate / Number: Place of issue:
Notarized affidavit
(with photo, fathers name & occupation, residence address and citizenship)
Address Details
Current Residential Address
Prominent Landmark
Contact Details / A/3,203,Gayatri Residency, Medatiya Nagar, Opp Seven Square academy, Mira Road East, Thane-401107
Deepak Hospital lane
Res. Number: A/3,203 Mobile Number: 9958214943
Exact period of stay at current address / From: 01 Nov, 2015 To: till date
Kindly indicate a convenient time for a physical address verification /
9AM to 5PM
Previous Addresses (Covering last 5 years)
Previous Address 1
Landmark
Period of Stay
Contact Details / K-304,Grand Manor Ideal park, Deepak hospital lane,Mira Road east,
Thane-401107
Deepak Hospital Lane
From: 30/11/2014 To: 30/10/2015
Res. Number: K-304 Mobile Number: 8087673250
Previous Address 1
Landmark
Period of Stay
Contact Details / B/107,Queens Avenue, Queens Park, Behind Deepak Hospital, Mira Road East Thane-401107
Deepak Hospital
From: 01/09/2014 To: 29/11/2014
Res. Number: B/107 Mobile Number: NA(society office will prove)
Previous Address 1
Landmark
Period of Stay
Contact Details / C-103, Shri ji Apartment, building-2, Kishore Nagar, Nilegaon, Nalasopara West, Mumbai- 401203.(I stayed here with Ratnesh Mishra(mob.9987422607) who was already residing there )
Sanjay Gandhi School
From: 02/03/2014 To: 31/08/2014
Res. Number: C-103 Mobile Number: 9987422607
Previous Address 1
Landmark
Period of Stay
Contact Details / B-35A, Second floor, Gali No- 3, South Ganesh Nagar,Delhi-92
(My some family members are still residing at the address.)
Mother Dairy
From: 01/02/2011 To: 01/02/2014
Res. Number: B-35A Mobile Number: 8010572703

Education Details

Highest Educational Qualification
Please ensure copy of degree certificate and mark sheet are attached
Name of the University
College Name / Indira Gandhi National Open University
Saint Xavier school, Patna(Study center of IGNOU)
University Address
College Address / Maidan Gadhi, New Delhi(IGNOU Head Office)
West Gandhi Maidan Marg, Patna - 800001
From (month/yr) / To (month/yr) / Graduated / Program / % / Class / Student ID No./Enrolment No.
Jan/2004 / Jun/2008 / MCA / o  Full Time-NO
o  Part Time -YES / 59.39 / second division / 040190088
Type of degree, certificate, diploma: / Graduation date (month/yr) / Subject Major
MCA / Jun/2008(exam held in Jun 2008)
Result announced in (Aug/2008) / Computer Science

Copy of the certificates attached? Yes


Employment Details

Details of current / latest employer
(In descending order covering last 5 years)
Company Name:
(1) / Mphasis Limited / Position Held
& Department / Delivery Module Lead
EMSBU
Address (main office where worked):
Mphasis Limited, Wing-B,1st floor,Infinity It park, building no-4,General AK Vaidya marg, Dindoshi, Malad East,Mumbai-400097,India / Telephone:
02267883000
Employment Period: (date, month, year)
From: 03/03/2014
To: till date / Employee Code:
2269667 / Supervisor’s Full Name
Anuradha
Designation:
Off no. Ext:
Cell no. 9731230193
Res no.
Whether employment is of permanent or temporary nature -
ü Permanent ¨ Temporary
Agency Details (if temporary or contractual)
Address:
Responsibilities: Design and development
Last salary drawn per month
CTC : per month
Gross : per month
Net : per month / Reason(s) for Leaving:
Can a reference be taken now? Yes / No
If no, when can it be taken?

** Fill in as much detail as possible and attach all documents.

Details of Previous Employer (2)
Company Name: / Ascent Cyber Solutions
(located in pune) / Position Held
& Department / Senior Software Engineer
IT
Address (main office where worked):
Worked in NOIDA for:
Pitney Bowes Software India Pvt Ltd. Noida,Sec-62 / Telephone:
Employment Period: (date, month, year)
From: 05/02/2013
To: 12/02/2014 / Employee Code:
1056 / Supervisor’s Full Name
Pavan Rathore
Designation: PM
Off no. Ext:
Cell no. 9881132045
Res no.
Whether employment is of permanent or temporary nature -
ü Permanent ¨ Temporary
Agency Details (if temporary or contractual)
Responsibilities: Designing and Coding
Last salary drawn
CTC : 53390(Rs.) per month
Gross : per month
Net : 47601(Rs.) per month / Reason(s) for Leaving:
For career growth

** Fill in as much detail as possible and attach all documents.

Details of Previous Employer (3)
Company Name: / SDG Software India Pvt. Ltd / Position Held
& Department / Software Engineer
Technology
Address (main office where worked):
SDG Software India Pvt Ltd.
A-10,Sec-2,Noida / Telephone:
Employment Period: (date, month, year)
From: 06/12/10
To: 01/02/2013 / Employee Code:
2262 / Supervisor’s Full Name
Rajneesh Mishra
Designation: Technical Architect
Off no. Ext:
Cell no. 8527698429
Res no.
Whether employment is of permanent or temporary nature -
ü¨ Permanent ¨ Temporary
Agency Details (if temporary or contractual)
Responsibilities:
Last salary drawn
CTC : 32248(Rs.) per month
Gross : per month
Net : 32248(Rs.) per month / Reason(s) for Leaving:
For career growth

** Fill in as much detail as possible and attach all documents.

Details of Previous Employer (4)
Company Name: / Position Held
& Department
Address (main office where worked): / Telephone:
Employment Period: (date, month, year)
From: DD/MM/YY
To: DD/MM/YY / Employee Code: / Supervisor’s Full Name
Designation:
Off no. Ext:
Cell no.
Res no.
Whether employment is of permanent or temporary nature -
¨ Permanent ¨ Temporary
Agency Details (if temporary or contractual)
Responsibilities:
Last salary drawn
CTC : per month
Gross : per month
Net : per month / Reason(s) for Leaving:

** Fill in as much detail as possible and attach all documents.


GAPS

Please account for all gaps in employment during the last five years.

From / To / Reason:
From / To / Reason:
From / To / Reason:
Letter of Authorization

To whom it may concern

I hereby authorize MphasiS and its representative to verify information provided in my resume and application of employment, and to conduct enquiries as may be necessary, at the company's discretion. I authorize all persons who may have information relevant to this enquiry to disclose it to MphasiS or its representative. I release all persons from liability on account of such disclosure.

Sign :

Name in Capitals : ASHUTOSH KUMAR PANDEY

Date : 11/03/2017


Mandatory Documents \ information required:

For Education Verification:

1.  Copies of the Marks Sheets/Grade Card for all the years of attendance.

2.  A photocopy of both the sides of the Degree Certificate (The reverse side of the certificate has information which the University requires).

3.  Name and address of the College \ University through which the candidate has graduated.

For Employment Verification

1.  Complete name of the employer along with the address and

contact numbers

2.  Employee code

3.  Supervisor full name, designation and direct contact numbers

4.  Relieving letter / Experience Letter / Service Certificate

For Identity Verification:

Photocopies of Primary Documents (Minimum of two – Passport is mandatory and the other one is any one of Election ID, Driving License or PAN Card)

1.  Current Passport copies – first & last sheet. Also, copies of other sheets (if any stamping is there)

2.  Election ID card

3.  Driving License

4.  PAN Card

Secondary Documents: (If primary documents not available)

1.  Birth Certificate

2.  Marriage Certificate (if applicable)

3.  Last 2 months Bank Statement

4.  Last 2 months Credit Card Statement

For Address Verification:

1.  Complete address to include, house number - lane number (where applicable), town, district, state, pin code number, etc.

2.  Prominent landmark

3.  Land line number

4.  Period of Stay

Original color photographs (2 numbers)

Current address proof (passport copy, electricity bill, telephone bill,

Credit card statement, PAN card)

For Criminal Verification refer to the list provided by HR.

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