Background Verification Form

3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.
www.integrityvs.com
Background Screening Form
CANDIDATE PERSONAL DETAILS
Applicant ID:
Full Name PRITAM BABASAHEB JAGDALE
Former Name(s) / First Middle Last

Maiden Name (If
applicable)
Father’s Name BABASAHEB RAOSAHEB JAGDALE
Address 1: Current:  Tirupati Soceity,
Address 2: Permanent:  Sr. No. 49/4+5, Usha Nivas, Sajjangad

Colony, Nakhate Vasti, Rahatni, Pimpri, Pune City, Pune
– 411017.
Gender: Male Date of Birth: (DD/MM/YY) 07/07/1992 (07-July-1992)
Contact number +91 8237040501, +91 9096439070
PAN Card number AOTPJ5626A

www.integrityvs.com
EDUCATION HISTORY (Highest Qualification Onwards)
Board / Full time / Seat / Roll/ Course Course

Exam
School/college University part time/ Registration Start End % Achi
Passed
and address affiliate to Distance number Date Date
MCA IBMR CCS University of Full time 10854 2013 2016
Wakad Pune Pune 65.1
411057
BCA IBMR CCS University of Full time 32174 2010 2013 63.7
Wakad Pune Pune
411057
12th MM Jr. College Maharashtra Full time P019420 2008 2010 50%
of Science, Board
Commerce &
Arts Thergoan,
Pune - 411033
10th MM Vidhyalaya Maharashtra Full time C053856 2007 2008 70.9
Kalewadi pimpri Board
pune 411017
Any other information you would like to provide (if any) : ______________________________________
Attention:
 Please mention any details for reexamination taken directly from the University or anything else you
would like to highlight.
 Please mention if you have attained qualification with correspondence studies and also enclose copy
mark sheet with roll no. clearly indicated.
 Please provide clear copy of the Final Year mark sheet / certificates for the education qualification
mentioned above.
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EMPLOYMENT HISTORY 1 (Current Employer)
Company Name : Clover Infotech Pvt. Ltd.
Address (Main Office and Branch where worked): 2nd Floor, Dhana Singh Processors
Building, Vazir Glass Lane, Andheri - Kurla, J B Nagar, Andheri East, Mumbai, Maharashtra
400059
Company Board Line Numbers (No Cell 022 2926 1650

Phone numbers accepted)
If Deputed by Agency - Agency name and NA
address
Tel no of the Agency NA

Employee Code CI5169
Designation and Dept Engineer – Technical Support
Date of Joining 13th December 2017
Date of Leaving 10th August 2018
Monthly Gross Salary 24010
Reasons For leaving Takeover the another vendor onwards Continue
with project
Supervisor’s Name and Designation Mr. Shailesh Chorage – Site MANAGER
Supervisor’s Official Mail ID [email protected]
Supervisor's direct Line Number and

Mobile no.
Any other information you would like to provide:
Attention:
 Please provide the Employee Code mandatorily and clearly
 Please provide a copy of the last Salary Slip of your Current Employer
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EMPLOYMENT HISTORY 2 (Previous Employer)
Company Name : Anutham Technology Pvt. Ltd.
Address (Main Office and Branch where worked): Opp. Kate Puram, Pimple Gurav,
Pune- 411061
Company Board Line Numbers (No +91 -02066208462
Cell Phone numbers accepted)
If Deputed by Agency - Agency name NA
and address
Tel no of the Agency NA

Employee Code ASE/01026
Designation and Dept Application Support Engineer
Date of Joining 15 - January - 2016
Date of Leaving 08 - December - 2017
Monthly Gross Salary 20000
Reasons For leaving Salary Issues
Supervisor’s Name and Designation
Supervisor’s Official Mail ID
Supervisor's direct Line Number and

Mobile no.
Attention:
 Please provide the Employee Code mandatorily and clearly
 Please provide a copy of the last Salary Slip of your Current Employer
 Please provide a copy of your Relieving Letter / Service Certificate for Employment
mentioned above
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PROFESSIONAL REFERENCE 1
Reference Name : Pratik Patel
Reference Relationship with the Candidate: L & T Finance Manager
Reference Email ID: [email protected]
Reference Mobile No: 9595940862
PROFESSIONAL REFERENCE 2
Reference Name : Suhas Warvadkar
Reference Relationship with the Candidate: Colleague
Reference Email ID: [email protected]
Reference Mobile No: 9028447072

www.integrityvs.com
Letter of Authorization
To whom it may concern
I hereby authorize IVS and any of its representatives to verify all the information provided
in my application of employment and to conduct such enquiries as may be required by
IVS to verify facts of such information provided by me. I hereby declare that this
authorization shall be valid till such time I remain an employee IVS
I hereby authorize all individuals, Private Establishments, Government

establishments/Agencies, Educational institutions who may have information relevant to
this enquiry to co-operate to IVS and/or its representatives such information as may be
required. I hereby release IVS, all its personnel and representatives from any liability
which could result, either directly or indirectly, from the disclosure of information by a third
party to another party in response to such enquiries.
Signature:
Name in Block Capitals: PRITAM BABASAHEB JAGDALE.
Date: 14th August 2018

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3rd Floor, Cambata Building, Above Eros Theatre, Jamshedji Tata Road, Churchgate, Mumbai – 400020.

Background Screening Form

CANDIDATE PERSONAL DETAILS

Former Name(s) / First Middle Last

Address 1: Current:  Tirupati Soceity,

Address 2: Permanent:  Sr. No. 49/4+5, Usha Nivas, Sajjangad

Gender: Male Date of Birth: (DD/MM/YY) 07/07/1992 (07-July-1992)

Contact number +91 8237040501, +91 9096439070

PAN Card number AOTPJ5626A

EDUCATION HISTORY (Highest Qualification Onwards)

Board / Full time / Seat / Roll/ Course Course

EMPLOYMENT HISTORY 1 (Current Employer)

Company Name : Clover Infotech Pvt. Ltd.

Company Board Line Numbers (No Cell 022 2926 1650

Tel no of the Agency NA

Supervisor’s Official Mail ID [email protected]

Supervisor's direct Line Number and

Any other information you would like to provide:

EMPLOYMENT HISTORY 2 (Previous Employer)

Company Name : Anutham Technology Pvt. Ltd.

Tel no of the Agency NA

Supervisor’s Official Mail ID

Supervisor's direct Line Number and

Any other information you would like to provide:

Reference Name : Pratik Patel

Reference Relationship with the Candidate: L & T Finance Manager

Reference Email ID: [email protected]

Reference Mobile No: 9595940862

Any other information you would like to provide:

Reference Name : Suhas Warvadkar

Reference Relationship with the Candidate: Colleague

Reference Email ID: [email protected]

Reference Mobile No: 9028447072

Any other information you would like to provide:

To whom it may concern

I hereby authorize all individuals, Private Establishments, Government

Name in Block Capitals: PRITAM BABASAHEB JAGDALE.

Date: 14th August 2018

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