Background Verification Form

Thank you for the interest shown in Virtusa. Please take a few minutes of your time to fill in the following
details to help us understand your technical skills and personal competencies better.

Please keep in mind the following when filling up the form:

1. Fill in the boxes in the application blank in bold capital

letters unless the content is of a descriptive nature.

2. Fill in the details according to the format mentioned

for the date and day.

NAME (As in Passport/ Govt ID) ___________________________________/__________________________________

___
Given Name Surname

a. Former Name (s) / Maiden Name (if applicable) -

b. Names & Previous Names Used in the last 7 years -

Father’s Name: Ramanna DS

Nationality: INDIA
Sex: Male Marital Status: Single

Place of Birth (City): Mandya

Date of Birth: ___________/__________/____________
DD MM YY Country of Birth: INDIA

ADDRESS Present Address Permanent Address

House No Shree mahadeshwara nilaya #1999
Foot ball nagegowda road kirgandur new
1 st floor subash nagar 3rd cross
Locality / City layout Marigowda badavane 3rd cross
mandya
mandya
State karnataka karnataka
PIN CODE 571401 571401
Period of Stay 1.5 years 10 years
 (Telephone)
 (Mobile Phone) 9738428508 9738428508
E-mail ID (Personal) Karthik1151403gttc@gmail.com Karthik1151403gttc@gmail.com

Instant Messaging System ID:

Passport No: U2930773 PAN No: EHOPR8794H SSN No. If any (Mandatory if studied in USA
or Canada)

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HR Dept. - FORMS –Application Blank.
Address History (List most recent first) - Please provide addresses for the last 7 years

Period of Contact Number

Complete Address along with Landmark
Stay Country Zip code with Relation ship
(MM/YYYY)
10/2008
To
09/2020 #1999 1st floor subash nagar 3rd cross mandya india 571401 9380379462

09/2020 Shree mahadeshwara nilaya Foot ball nagegowda

rd
road
To kirgandur new layout Marigowda badavane 3 cross
mandya 571401 karnataka india 571401 9380379462

Family Information (Parents, Brothers, Sisters, Spouse & Children)

S.No Name Relationship Date of Birth Age

1 Lakshmi Devi mother 1970 52

2 Krupa Shree SR sister 10-07-1993 29

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HR Dept. - FORMS –Application Blank.
EDUCATION INFORMATION
Duration Graduatio
Program (full- University Name n Date
Degree Course time/Part-time) Elective College Name and Address and Address From To % (MM/YY)

Twinkle united public Karnataka state

X SSLC Full time school mandya board 2012 2013 78 2013

Govt tool room

Govt tool room and and training
XII /Diplomo DTDM Full time training centre centre 2013 2017 80 2017

BE in BGS Institute of
Graduation mechanical Full Time technology VTU 2017 2020 80 2020

PG

Others 1

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HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (1) : Cognizant Technology Solutions India Last Designation held: Programmer Analyst
Pvt Ltd

Address (main office and branch where worked): Embassy Telephone: (044) 42096000 47426000, +1
Manyata Business Park, Opposite Bel Corporate House, 201 801 0233
Rachenahalli, Nagawara-560045

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From : 12/12/20020 To : 4/01/2022 No: 894454 Manager Shaik Abdulla

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) : 450000 rupees Reason(s) for Leaving : Due to less project

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HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (2) : Last Designation held:

Address (main office and branch where worked): Telephone:

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From To No: Manager

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) Reason(s) for Leaving

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HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (3) : Last Designation held:

Address (main office and branch where worked): Telephone:

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From To No: Manager

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) Reason(s) for Leaving

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HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (4) : Last Designation held:

Address (main office and branch where worked): Telephone:

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From To No: Manager

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) Reason(s) for Leaving

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HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (5) : Last Designation held:

Address (main office and branch where worked): Telephone:

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From To No: Manager

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) Reason(s) for Leaving

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HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (6) : Last Designation held:

Address (main office and branch where worked): Telephone:

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From To No: Manager

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) Reason(s) for Leaving

Virtusa Ver: 1.8 PPaaggee 99 ooff 1133

HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (7) : Last Designation held:

Address (main office and branch where worked): Telephone:

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From To No: Manager

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) Reason(s) for Leaving

Virtusa Ver: 1.8 PPaaggee 1100 ooff 1133

HR Dept. - FORMS –Application Blank.
 Details of Previous Employers (Starting from your Current Job, covering up to Last 5 Years of employments)
Please attach a copy of your relieving letter/service certificate for this

Company Name (8) : Last Designation held:

Address (main office and branch where worked): Telephone:

Employment Period: (date, month, year) Employee Code/ Personnel Name of Reporting
From To No: Manager

Name of HR: Contact No. of HR: Email Id of HR:

Designation & Department of Reporting Manager Contact No of Reporting Email ID of Reporting

Manager: Manager:

Name of Alternative Reporting Manager Contact No of Alternative Reporting Manager:

Designation & Department of Alternative Reporting Email ID of Alternative Reporting Manager:

Manager

Whether employment is of permanent or temporary nature -  Permanent  Temporary

Agency Details (if temporary or contractual)

Remunerations (CTC pa) Reason(s) for Leaving

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HR Dept. - FORMS –Application Blank.
 3.Please declare whether there is any gap between education or employments?
(Please tick) Yes / No.
If Yes, Please declare the details of your residence address for any/and all gaps between education or
employment during your tenure.

From To Reason: Complete Address and

Location

From To Reason: Complete Address and

Location

From To Reason: Complete Address and

Location

REFEREES - Please give two references of which one should necessarily be from your Present
Work Place.
No of Mths /
Name & Designation Current Company Official Mail ID Contact Details
Yrs Of Acquaintance

Avinash lm
Programmer analyst
Cognizant Avinash.LM@cognizant.com 9739478141 1 year

Narsimha
Programmer analyst Cognizant Narsimha@cognizant.com 9513236984 1 year 2 month

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HR Dept. - FORMS –Application Blank.
 4. Please declare whether you have directorship in any company?

(Please tick) Yes / No.

If Yes, please provide the details. (*) Fields are mandatory

Directorship Details (If applicable)

*Company Name

Company/Operation Closed

Functional
Company Status
Re-Located

Merged with ___________________________________

Company also Known as

*Complete Company Address
with Landmark (Where
Candidate has worked)
*Company Contact Number

*City *State
*Date of Joining
(DD/MMM/YY)
*Date of Exit (DD/MMM/YY)

Reason for Leaving

DIN Number

*Documents Submitted

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HR Dept. - FORMS –Application Blank.
 Declaration and Authorization
virtusa
Iunderstand that any employment by Virtusa India Private Limited or its
affiliated companies is conditioned
upon positive responses from my references, bonding eligibility, continued
Limited policies and procedures, applicable rules and adherence to Virtusa India Private
to Virtusa India Private Limited.
regulations and job performance satisfactory at all times

I consent to take any pre or

post-employment examinations as may be required by Virtusa India Private
Limited or its permitted agents, its
representative, and release Virtusa India Private Limited and its agents
from any liability that may arise from such examination.

I authorize an inquiry to be made on the

information contained on this application. Former
officials of education institutes, named on this employers and
release them from all liability for
application are authorized to give information about me and
such information.
issuing
hereby attest and warrant that all
my answers on this
application as well as on all forms completed in
conjunction with my
employment are true and accurate.I understand that my
failure to disclose information misrepresentation of facts,
required on this application or material change in my information provided
which is not reported to Human Resources shall be cause for
dismissal regardless of when discovered by
Virtusa India Private Limited

understand, and authorize, that Virtusa may share my consumer report and/or investigative report with third
parties including auditors, government agencies, and clients as necessary.
I hereby declare that the information given by me is true and the certificates or documents submitted are
genuine to the best of my knowledge.

Signed:
Name in Block Capitals: hARTHIK SK
Date: 2hloll22

Virtusa Ver: 1.8

virtusa HR Dept. FORMS-Application Blank.