MOLEX INDIA BUSINESS SERVICES PRIVATE LIM

CRYSTAL KALYANI PLATINA, 2ND & 3RD FLOOR,

KUNDALAHALLI VILLAGE, K.R PURAM HOBLI,
BANGALORE – 560 066

Mandatory Fileds - To be filled by Employee

Optional - To be filled by Employee
Mandatory Fileds - To be filled by HR

EMPLOYEE JOINING INFORMATION

FULL NAME (BLOCK LETTERS)*
First Middle

DATE OF JOINING (DD / MM / YYYY)

DD MM
EMPLOYEE CODE (SAP NO) SOURCE
DESIGNATION DEPARTMENT
DATE OF BIRTH (DD MM YYYY) 05
DD MM
GENDER
FATHER’S NAME: RELIGION
EMAIL MOBILE
MARITAL STATUS BLOOD GROUP

CURRENT ADDRESS VILLAGE/CITY

DISTRICT
STATE
PINCODE

PERMANENT ADDRESS VILLAGE/CITY

DISTRICT
STATE
PINCODE
PERSONAL IDENTIFICATION
PAN CARD AADHAAR
PASSPORT NUMBER DATE OF ISSUE
DRIVING LICENSE NO. DATE OF ISSUE
EMPLOYEMENT DESIRED
ANY PAST EMPLOYMENT WITH
WHERE & WHEN, IF YES
MOLEX(YES/NO)
HAVE YOU BEEN INTERVIEWED BEFORE WITH
WHERE & WHEN, IF YES
MOLEX (YES/NO)
DO YOU HAVE ANY RELATIVES WORKING WITH
NAME & RELATIONSHIP, IF YES
MOLEX(YES/NO)

DO YOU HAVE ANY LAPSES IN EMPLOYEMENT DATES & REASONS FOR LAPSES
(YES/NO) IN EMPLOYEMENT, IF YES

FOR MARRIED EMPLOYEES

SPOUSE NAME
First Middle

EMERGENCY CONTACT DETAILS

NAME OF THE PERSON
CONTACT PERSON (LOCAL LANGUAGE)
RELATIONSHIP
MOBILE
QUALIFICATION DETAILS (FROM SSLC TO PG)
INSTITUTION NAME COURSE NAME
PLACE OF STUDY (CITY) COUNTRY
START DATE (DD/MM/YYYY)
COMPLETION DATE (DD/MM/YYYY)

INSTITUTION NAME COURSE NAME

PLACE OF STUDY (CITY) COUNTRY
START DATE (DD/MM/YYYY)
COMPLETION DATE (DD/MM/YYYY)

INSTITUTION NAME COURSE NAME

PLACE OF STUDY (CITY) COUNTRY
START DATE (DD/MM/YYYY)
COMPLETION DATE (DD/MM/YYYY)

INSTITUTION NAME COURSE NAME

PLACE OF STUDY (CITY) COUNTRY
START DATE (DD/MM/YYYY)
COMPLETION DATE (DD/MM/YYYY)

INSTITUTION NAME COURSE NAME

PLACE OF STUDY (CITY) COUNTRY
START DATE (DD/MM/YYYY)
COMPLETION DATE (DD/MM/YYYY)
 PREVIOUS EMPLOYERS HISTORY (FROM LATEST)

NAME OF THE COMPANY DESIGNATION

NATURE OF BUSINESS TELEPHONE, IF KNOWN
ADDRESS
DESCRIPTION OF DUTIES
REASON FOR LEAVING
DURATION (YEARS)
JOINING DATE (DD/MM/YYYY)
LEFT DATE (DD/MM/YYYY)

NAME AND TITLE OF IMMEDIATE SUPERVISOR

STARTING SALARY FINAL SALARY

NAME OF THE COMPANY DESIGNATION

NATURE OF BUSINESS TELEPHONE, IF KNOWN
ADDRESS
DESCRIPTION OF DUTIES
REASON FOR LEAVING
DURATION (YEARS)
JOINING DATE (DD/MM/YYYY)
LEFT DATE (DD/MM/YYYY)

NAME AND TITLE OF IMMEDIATE SUPERVISOR

STARTING SALARY FINAL SALARY

NAME OF THE COMPANY DESIGNATION

NATURE OF BUSINESS TELEPHONE, IF KNOWN
ADDRESS
DESCRIPTION OF DUTIES
REASON FOR LEAVING
DURATION (YEARS)
JOINING DATE (DD/MM/YYYY)
LEFT DATE (DD/MM/YYYY)

NAME AND TITLE OF IMMEDIATE SUPERVISOR

STARTING SALARY FINAL SALARY

NAME OF THE COMPANY DESIGNATION

NATURE OF BUSINESS TELEPHONE, IF KNOWN
ADDRESS
DESCRIPTION OF DUTIES
REASON FOR LEAVING
DURATION (YEARS)
JOINING DATE (DD/MM/YYYY)
LEFT DATE (DD/MM/YYYY)

NAME AND TITLE OF IMMEDIATE SUPERVISOR

STARTING SALARY FINAL SALARY

NAME OF THE COMPANY DESIGNATION

NATURE OF BUSINESS TELEPHONE, IF KNOWN
ADDRESS
DESCRIPTION OF DUTIES
REASON FOR LEAVING
DURATION (YEARS)
JOINING DATE (DD/MM/YYYY)
LEFT DATE (DD/MM/YYYY)
NAME AND TITLE OF IMMEDIATE SUPERVISOR

STARTING SALARY FINAL SALARY

3 PROFESSIONAL REFERRANCES
Name Job Title Telephone Number

I hereby declare that the above information provided by me is true and accurate to the best of my knowledge

SIGNATURE DATE
PLACE
`
S SERVICES PRIVATE LIMITED
PLATINA, 2ND & 3RD FLOOR,
VILLAGE, K.R PURAM HOBLI,
ALORE – 560 066

DESIGNATION

JOINING INFORMATION

Last

YYYY

YYYY

O+

NAL IDENTIFICATION

OYEMENT DESIRED

ARRIED EMPLOYEES

Last

NCY CONTACT DETAILS

DETAILS (FROM SSLC TO PG)
YERS HISTORY (FROM LATEST)
SIONAL REFERRANCES
Relationship

s true and accurate to the best of my knowledge.

 Name:
POSITION: 0

Molex is an Equal Opportunity Employer

Molex is an Equal Opportunity Employer
Personal Information Application Date 30/12/1899

Name 0 0

Last First Middle

Present Address ,,,,,

Permanent Address ,,,,,

Residence Telephone Email 0

Cellphone 0

Referred By

Employment Desired

Position 0 Salary

Date you can Join //

Have you ever been
employed by Molex? If Yes, When and Where?
Have you ever been
Interviewed by Molex? If Yes, When and Where?
Molex is an Equal Opportunity Employer
 Education Name of InstituteGraduated Course of Study/Degree

Yes No

High School NO

College/university NO

College/university NO

Other Training/PG NO

Are you 18 Years or Older YES/NO YES

Do you have any relatives who are currently employed at Molex? Relatives include parents,
spouse, children, sibling, grandparents, aunts, uncles, cousins, in-laws, step relatives, domestic
partners, or significant others.

If yes, state name and relationship

Molex is an Equal Opportunity Employer

Name Of The Company Designation
Phone No., if
Nature Of Business known

Address

Description Of Duties

Reason For Leaving

Duration (Years) Joining Date //

Name And Title Of
Immediate Supervisor Left Date //

Starting Salary Final Salary

Name Of The Company Designation

Phone No., if
Nature Of Business known

Address

Description Of Duties

Reason For Leaving

Duration (Years) Joining Date //

Name And Title Of
Immediate Supervisor Left Date //

Starting Salary Final Salary

Name Of The Company Designation

Phone No., if
Nature Of Business known

Address

Description Of Duties

Reason For Leaving

Molex is an Equal Opportunity Employer
Duration (Years) Joining Date //
Name And Title Of
Immediate Supervisor Left Date //

Starting Salary Final Salary

Molex is an Equal Opportunity Employer

Dates and Reasons for lapses in employement

Signed Date 30/12/1899

S.No Name Title Phone No Relationship

1
2

Molex is an Equal Opportunity Employer

Molex is an Equal Opportunity Employer
Molex is an Equal Opportunity Employer
Molex is an Equal Opportunity Employer
30/12/1899

Molex is an Equal Opportunity Employer

Course of Study/Degree

Molex is an Equal Opportunity Employer

//

//

//

//

Molex is an Equal Opportunity Employer

//

//

Molex is an Equal Opportunity Employer

 Relationship

Molex is an Equal Opportunity Employer

Molex is an Equal Opportunity Employer
MOLEX INDIA BUSINESS SERVICES PVT LTD
MOLEX INDIA BUSINESS SERVICES PVT LTD

DECLARATION FOR COVERAGE UNDER GROUP MEDICLAIM POLICY

Date of Birth DOJ / DOM

# Emp No. Employee Name Insured Name (DD/MM/YYYY) Gender Relationship (If Spouse) Declared Date

1 0 /5/ 0 SELF //

Note : Coverage of parents under Group Medical Insurance is voluntary and the full premium will be recovered from employee's salary.

Employee Signature -
Date //

AON Global Insurance Brokers Pvt. Ltd. Sreeja M Authorized Signatory -

Date - Sr.Executive - HR (T.A Team)

Form needs to be submitted to HR Team

 NOMINATION AND DECLARATION FORM F
Declaration and Nomination Form under the Em
(Paragraph 33 and 61 (1) of the Employees Pr

1. Name (IN BLOCK LETTERS) : 0

Name

2. Date of Birth :
/5/

4. *Sex : MALE/FEMALE:
30/12/1899

6. Address Permanent / Temporary : ,,,,,

PA
I hereby nominate the person(s)/cancel the nomination made by me previous
credit in the Employees Provident Fund, in the event of my death.

Name of the Nominee (s) Address

1 2

1 *Certified that I have no family as defined in para 2 (g) of the

the above nomination should be deemed as cancelled.
2. * Certified that my father/mother is/are dependent upon me.
Strike out whichever is not applicable
 PA

I hereby furnish below particulars of the members of my family who

premature death in service.

Sr. No Name & Address of the Family Me

(1) (2)

Certified that I have no family as defined in para 2 (vii) of the Empl

I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly wid
without leaving any eligible family member for receiving pension.

Name and Address of the nominee

 CERTIFICA
Certified that the above declaration and nomination has been si
my establishment after he/she has read the entries / the entries have b

Date : 30/12/1899

Place : 0
ORM FOR UNEXEMPTED/EXEMPTED ESTABLISH
the Employees Provident Funds and Employees Pensio
mployees Provident Fund Scheme 11252 and Paragraph 18 of the Employees Pension
Scheme 112125)

Father's/Husband's Name Surname

3. Account No.

5. Marital Status
30/12/1899

PART – A (EPF)
e previously and nominate the person(s) mentioned below to receive the amoun

Total amount or
share of
Nominee’s
accumulations in
Date of Birth relationship with the
Provident Funds to
member
be paid to each
nominee

3 4 5

(g) of the Employees Provident Fund Scheme 11252 and should I acquire a

me.

Signature/or thumb impression

Of the subscriber
 PART – (EPS)
Para 18
mily who would be eligible to receive Widow/Children Pension in the ev

mily Member Age

2) (3)

he Employees’s Family Pension Scheme 112125 and should I acquire a

nthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the ev
nsion.

Date of Birth Relationship wit

 Signature or thumb impression of the subscr

TIFICATE BY EMPLOYER
been signed / thumb impressed before me by Shri / Smt./Miss....
es have been read over to him/her by me and got confirmed by him/her

Signature of the employer or other authorise

establishment

Name & address of the Factory /Establishm

 (FORM 2 REVISED)

EMPTED ESTABLISHMENTS
and Employees Pension Schemes
ned below to receive the amount standing to my

If the nominee is minor

name and address of the
guardian who may receive
the amount during the
minority of the nominee

e 11252 and should I acquire a family hereafter

thumb impression
riber
ow/Children Pension in the event of my

Relationship with the

member
(4)

12125 and should I acquire a family hereafter

ra 16 2 (a) (i) & (ii) in the event of my death

Relationship with member

umb impression of the subscriber

me by Shri / Smt./Miss.... ....employed in

and got confirmed by him/her

e employer or other authorised officer of the

ss of the Factory /Establishment (Seal)

 FORM 'F'
(See sub-rule (1) of Rule 6)

Nomination

1. I, Shri /Shrimati /Kumari……. ……..(Name in full here) whose

statement below, hereby nominate the person(s) mentioned below
after my death as also the gratuity standing to my credit in the ev
amount has become payable, or having become payable has not b
amount of gratuity shall be paid in proportion indicated against th

2. I hereby certify that the person(s) mentioned is/are a member(s) o

meaning of clause (h) of Section 2 of the Payment of Gratuity Ac
3. I hereby declare that I have no family within the meaning of clau
Act
4. (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on m

5. I have excluded my husband from my family by a notice dated th

controlling authority in terms of the proviso to clause (h) of Secti

6. Nomination made here in invalidates my previous nomination

NOMINEE(S)
Name in full with full
Relationship with the
address of
employee
nominee(s)
 Statement

7.
Name of employee in full :
8.
Sex :
9.
Religion :
10.
Whether unmarried/married/widow/widower :
11.
Department/Branch/Section where employed :
12.
Post held with Ticket No :
13.
Date of appointment :
14.
Permanent address :

Village Post Office District S

0 0

Place: 0 -----------------------
Signature/Thumb
 Declaration by Witnesses

Nomination Signed/thumb impressed before me

Name in full and full address of witnesses

Place 0

Date 30/12/1899

Certificate by the Employer

Certified that the particulars of the above nomination have been verified & re

Employer's Reference No., if any Signature of the

Desi

Date 30/12/1899

Name and address of the establishment or rubber stamp thereof.

Molex (India) Business Services Pvt. Ltd

Crystal Kalyani Platina, Kundalahalli Village,
Bangalore- 560066
 Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly

30/12/1899
Date:

Place 12/30/1899
M 'F'
(1) of Rule 6)

nation

ame in full here) whose particulars are given in the

son(s) mentioned below to receive the gratuity payable
ng to my credit in the event of my death before that
ecome payable has not been paid and direct that the said
rtion indicated against the name(s) of the nominee(s).

ned is/are a member(s) of my family within the

Payment of Gratuity Act, 1972.

hin the meaning of clause (h) of Section 2 of the said

ependent on me.

s/are not dependent on my husband

mily by a notice dated the ---------------------to the

so to clause (h) of Section 2 of the said Act.

previous nomination

INEE(S)
Proportion by which
Age of
the gratuity will be
nominee
shared
ement

0
0
0
0

//

State
0

---------------------------------------------------
Signature/Thumb-impression of the Employee
by Witnesses

re me

Signature of witnesses

--------------------------------------------

--------------------------------------------

the Employer

on have been verified & recorded in this establishment.

Signature of the employer/Officer authorized

Designation

rubber stamp thereof.

 by the Employee

m 'F' filed by me and duly certified by the employer.

Signature of the Employee

 FORM No. 25
1[(See Rule 127)]
I hereby declare that in the event of my death before
resuming work, the balance of my pay due for the period of
leave with wages not availed of shall be paid to..... . . . . . w
is my . . . . . . and resides at, . . . . . . .

1. Witness . . . . . . . . . . . . .
..

2. Witness . . . . . . . . . . . . .
..

Date . . . . . . . . . . . Signature or thumb impression of the work

..
 FORM No. 25
1[(See Rule 127)]
e that in the event of my death before
, the balance of my pay due for the period of
es not availed of shall be paid to..... . . . . . who
and resides at, . . . . . . .

Signature or thumb impression of the worker

 Molex, LLC.
Code of Business Conduct and Eth
I, acknowledge that I have received a copy of the Koch Code of Bus
and Ethics. I have read the sections for which I am responsible, and
opportunity to ask questions about the policy and the sections descri
understand that it is my responsibility to follow the policies, practice
forth by the company and my compliance with the policies is a term
continued employment.

I understand that the company has a right to modify, amend or withd

the policies and procedures described in this document at any time.

Name :

Signature :

Date : 30/12/1899

SAP : 0
SAP : 0
Molex, LLC.
iness Conduct and Ethics
ed a copy of the Koch Code of Business Conduct
ns for which I am responsible, and have an
ut the policy and the sections described in it. I
bility to follow the policies, practices and rules set
mpliance with the policies is a term and condition of

s a right to modify, amend or withdraw any or all of

ibed in this document at any time.