Advt. Code No.

KERALA STATE ELECTRONICS DEVELOPMENT CORPORATION LIMITED TRIVANDRUM VERIFICATION REPORT

(To be filled up in own handriting with ball point pen in BLUE colour) 1. Name (in block letters) : :

2. a) Present Address (in block letters)

Affix a recent Passport size Photo b) Phone No. (Landline & Mobile) with STD code : c) E - mail id 3. a) Permanent Address (in block letters) : :

b) Residential telephone (with STD code) 4. a) Age b) Date of Birth 5. a) Religion b) Caste c) Category 6. 7. Sex Physical Characteristics If Physically Challenged, furnish details 8. 9. Marital Status Family details Name

: : : : : : : : : : : Age Occupation (if employed give designation & full address) Present / Permanent Address General/ SC/ST/OBC (Male/Female) Normal/Physically challenged

Sl. Relationship No. i ii Father Mother

iii

(Brother(s)/Sister(s))

iv

Wife/Husband

Children

10.

Identification Marks i ii Name : : : Specify relatives, if any employed in Keltron Group of Companies Specify relationship with Directors of the Corporation Post Applied for Employment Exchange Registration Number and Date, if any Previous employment history : Name & Address of previous employer From Period Designation To Nature of work Emoluments Reasons with grade for leaving if any : :

11.

Designation Name

Relationship : 12. 13. 14. 15. Sl. No. Relationship :

16.

Academic Record (including course attended) Date of entry Date of leaving Examination Passed Subject / Branch Class/ Rank % of Marks Year of Passing

Name of Institutions with address

17. 18.

If selected approximate time required to join duty (i)

: (ii)

Name and address of two reference (with phone no./e - mail id, if available)

DECLARATION I declare that the above furnished details are true and correct to the best of my knowledge and belief. I am aware that in the event of my furnishing any false information, the Management reserves its right to terminate my service without notice or pay in lieu thereof.

Place : Date :

SIGNATURE OF CANDIDATE