Candidate Declaration Form

Personal Details Name of the Applicant: Fathers Name: BRIJESH KUKREJA Contact No:9896043326, 9034418058 Sex :MALE

RAM CHAND KUKREJA

Date of Birth :14 AUGUST 1991

Previous Employment 1 Name of Company Company Address (Where you were employed) (Landline) Period of Employment (dd/mm/yy) Designation From; To: / / / Department / Division Rs. / Employee Code

Last Salary Drawn

Person You Reported To Reporting Manager Contact Details

Name:Direct Landline No-

Designation:Mobile NoE Mail ID-

Previous Employment 2 Name of Company Company Address (Where you were employed) (Landline) Period of Employment (dd/mm/yy) Designation From; To: / / / Department / Division Rs. / Employee Code

Last Salary Drawn

Person You Reported To Reporting Manager Contact Details

Name:Direct Landline No-

Designation:Mobile NoE Mail ID-

Education: Please provide the details of Highest Degree / Diploma Details Name & Address of University / Affiliated Institute Name of Degree /Diploma (Also indicate specialization) MBA (MARKETING AND IB) KUK B.COM REGULAR 2007 2010 Course Attended (Regular/ Correspondence) Dates Attended From 2010 To 2012 07-GK-260 Roll No / Registration No:

Name & Address of School/College/Institute

BUDHA COLLEGE OF MANAGEMENT , KARNAL GOVT. P.G. COLLEGE KALKA

Professional Reference 1

Professional Reference 2

Professional Reference 3

Name Organization & Location Position Telephone ( Landline / Mobile ) Relationship

PUNKAJ GOEL INDIAN OVERSEAS BANK ASSISTANT MANAGER 9896662858 STUDENT

CURRENT ADDRESS OF THE EMPLOYEE:

1673 ,B-2 V.K. COLONY, PINJORE, DISTRICT -PANCHKULA ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ _________________________PIN____134102______________

PERMENENT ADDRESS OF THE EMPLOYEE:

____________- DO -__________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ _________________________PIN________________________

Note: Please attach legible copies of the following supporting documents, relevant to the entries made above.

Photocopy of Appointment / Salary Slips / Resignation / Release Letters of the Previous Employer. (Any one can be applicable) Details of Current and Permanent Address. (Any landmark if possible) Photocopy of Educational Certificates (Mark sheet / Highest Degree Certificate) and College or Institute Name.

Authorization/ Declaration and Undertaking:

I certify that the statements made in this application are valid and complete to the best of my knowledge. I understand that false or misleading information may result in termination of employment. If upon investigation, any of this information is found to be incomplete or inaccurate, I understand that I will be subject to dismissal at any time during my employment.

I hereby authorize Client, and/or any of its subsidiaries or affiliates, and any persons or organization acting on its behalf to verify the information presented on this application form and to procure an investigation report or consumer report for that purpose. I hereby grant authority for the bearer to access or to be provided with full details of my previous record. In addition, please provide any other pertinent information requested by the individual presenting this authority. I hereby release from liability all persons or entities requesting or supplying such information. I authorize to contact my present and past employer. Yes No

I have read, understand, and by my signature consent to these statements. Date: 21 MAY 2012

Full Name: BRIJESH KUKREJA

Signature: