Pfizer Healthcare India Private Limited

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Employment Application
(Please fill in legible handwriting)
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Position Applied for:

Department:

Part A: Personal Details -

Name :(First) (Middle) (Last)

Local / Mailing Address: Permanent Address:

Pin: Pin:

Period of Stay: Period of Stay:

Telephone: Mobile: Email Id:

Person to be notified in case of Emergency (Name):

Address:

Telephone:

Nationality Place of Birth Home Town

Age Birth Date (dd/mm/yy) Gender: M / F Blood Group Height(cms) / Weight(kgs)

Marital Status Marriage Date (dd/mm/yy)

No. of Dependents: Relation Name Occupation

Parents:
Father
Spouse:
Spouse
Children:
 Do you have relatives employed by this Company? (If yes, provide details)

Name: Relationship: Department:

Identification Details:

PAN No Passport No
AADHAR No. Issue Date (dd/mm/yy)
Expiry Date (dd/mm/yy)
State

Part B: Education Details

Highest Education Completed

Name of the Institute/School/College :
Board/University : Degree Obtained :
Duration of Study (specify Year & Month): Division/Class/% :

Majored in : Course Type : Regular [ ] Distance [ ]

Student ID / Enrolment Id / Registration No. / Roll No:
Building No & Street:

Address of Institute/School/College City: State:

Pin: Landline :

Second Highest Education Completed

Name of the Institute/School/College :

Board/University : Degree Obtained :
Duration of Study (specify Year & Month): Division/Class/% :

Majored in : Course Type : Regular [ ] Distance [ ]

Student ID/ Enrolment Id /Registration No. / Roll No:
Building No & Street:

Address of Institute/School/College City: State:

Pin: Landline :

Note: Please attach legible photo copies of the following documents relevant to the entries above.

1) Mark sheets 2) Degree Certificate 3) Provisional Degree Certificate

Professional Certification
Full Time/Part Employee
Sr. No. Qualification Institute Name & Address Duration of Course
Time Id/Roll No.

Part C: Previous Employment Details

Employment - 1

Name of Company:
Building No & Street:
Company Address
City: State:
(Where you were employed )
Pin: (Landline):

Joining Date: Relieving Date: Employee ID:

Designation & Department: Last Drawn Salary (CTC):

Type of Employment: Permanent [ ] Contractual [ ] Part time [ ] Full Time [ ]

Supervisor’s Name & Designation: Supervisor’s Direct Number & Mail Id:

Can the employer be contacted now? [ ] Yes [ ] No

If not, then provide an alternate date:

Reason for Leaving:

Employment - 2

Name of Company:
Building No & Street:
Company Address
City: State:
(Where you were employed )
Pin: (Landline):
Period of employment: Employee ID:
Joining Date: Relieving Date: Last Drawn Salary (CTC):

Type of Employment: Permanent [ ] Contractual [ ] Part time [ ] Full Time [ ]

Supervisor’s Name & Designation: Supervisor’s Direct Number & Mail Id:

Can the employer be contacted now? [ ] Yes [ ] No

If not, then provide an alternate date:

Reason for Leaving:

Note: Please attach legible photo copies of the following documents relevant to the entries above.

1) Last Salary Slip 2) Relieving letter

Have you ever been convicted of a crime or is any criminal case pending against you? Yes No

Has there been any disciplinary proceeding initiated or punishment/penalty/awarded to you? Yes No

Have you had any major illness, operation or accident? Give details. `` Yes No

When can you join if selected? Are you willing to be posted anywhere in India?

Who referred you to this Company? Have you ever applied to this Company before?

Yes No (If yes, indicate year & position)

References (Outside Pfizer and Not Relations):
At least one reference should be that of a previous employer, business contact or teacher / guide at an
educational institute.

Name Designation / Occupation Email Id & Telephone Number

1.

2.

3.

I hereby confirm that information / statements provided by me in this application form are accurate and can
be verified by Pfizer. I authorize ‘Pfizer’ to verify my credentials through their channel partners/vendors.

I accept that I shall cooperate and furnish further documentation/details if required. I further accept that I
shall be liable for dismissal from service if the furnished details are found to be misrepresentation of facts.

I have read and understood the above points. I submit this document voluntarily, with full knowledge of its
effect.

Place:

Date:
Signature