An Suman

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IBM Application ID * C

FILL ALL DETAILS IN CAPITAL LETTERS

*Title

*First Name / Given Name Middle Name

*Last Name / Family Name Father's Name

*Date of Birth *Mobile Number

Please affix your passport size photo here

ASHOK KUMAR SATAPATHYSATAPATHY

DD Country Code

If you have already registered on o ur IBM Job Portal please provid e the IBM Candidate Applicant ID also called GOM

Candidate Applicant ID. If you are referred by an Agency, please ask your agency for t he Applicant ID

* Enter your name as per your Passport, Driver's Licence, PAN Card or Or any Govt issu ed Photo Identity card (For Indian

Nationals)

Employment Application Form

YYYY

Mr.

Mobile Number

GBS-A36895453-17837906

ANSUMAN

MMM

*

Personal Email ID Telephone (Landline)

PAN Card Passport Number

Place of Issue of Passport Expiry Date

*Nationality Country Of Birth City Of Birth

*SOURCE INFORMATION - How did you kn ow about this vacancy in IBM? (Select any one of the below )

Country Code

[email protected]

DD MMM

City Code Phone Number

2462522+91

2024

X Direct

Referrer's E- Mail ID

Enter Agency name

AugBHUBANESWAR 26

Name of the Employee

(Referrer Name)

M0986363

YYYY

0661

Job SiteEnter the jobsite name

here

Social Networks (Website

Name -Facebook/ LinkedIn/

Twitter/ Google+)

Employee

Referral

Agen cy

INDIAN CHATRAPURINDIA

Referrer's employee

Number

Page 1 of 8, Employment Applicatio n for m V 02, wef - 11th May 2015

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Please complete all fields, even if you have already provi ded a resume. Provide details on COMPLETED degree programs onl y.

*Highest Qualification (Completed) ** e.g.: M.Sc, B.Com

**Highest completed degree / diploma awarded by a University / Board or its affiliates and or approved by UGC / AICTE / Ministry of HRD / Government of India

Start Date

End Date

Year Of Passing

Start Date

End Date

EDUCATION DETAILS (Fill in CAPITAL Letters)

Name of the

DegreeAwar ded

(e.g.. B.com /

BA/ Mtech)

Registration /

Roll / Final

Year Seat

Number

Percentage/

Grade Points

Complete Name & Address of School / College / Institution andName of the University

*University name is mandatory where applicable(DO NOT ABBREVIATE)

Course Tenure

B.TECH

Qualification

Mar

2008Apr

XthCENTRAL BOARD OF SECONDARY EDUCATION, BHUBANESWAR

University

Details (Name& Address) if

applicable

2009

Mar

School/

College/

Institution

details (Name

& Address

HSLC 12thHSLC 12th

2011

MMM YYYYDEEPIKA ENGLISH MEDIUM SCHOOL ,SEC-5 ROURKELA 769003

86.80% 6606414 XIIth

Apr 2010

SSLC (10th) 518333389%

DEEPIKA ENGLISH MEDIUM SCHOOL ,SEC-5 ROURKELA 769003School/

College/

Institution

details (Name

& Address

YYYYMMM

2009May

Year Of Passing

Start Date

End Date

Year Of Passing

Start Date

End Date

Year Of Passing

,

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY ,B HUBANESWAR

B.TECH-

EEE(Electronics

and Electrical

Engg.)

8.29 B312007

2011

Graduation

University


applicable

University


applicable

Sep 2012

YYYY School/

College/

Institution

details (Name

& Address

School/

College/

Institution

details (Name

& Address

YYYYMMM

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY ,B HUBANESWAR

May

University


applicable

Page 2 of 8, Employment App lic ation f orm V 02, wef - 11th May 2015

May 2016

May 2016

Post Graduation

MMM

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M M M Y Y Y Y

Start Date

End Date

Year Of Passing

State reasons fo r GAP in education, if any :

Professional Training (inclu des in progr ess degrees) - please mention the details

University

Details (Name

& Address) if

applicable

Preparing for 1 year for entrance after 12th.

Others - PhD,

Additi onal

Degrees

School/

College/

Institution

details (Name

& Address

EDUCATION DETAILS - contd. (Fill in CAPITAL Letters)

Qualification Course Tenure

Complete Name & Address of School / College / Institution and

Name of the University

*University name is mandatory where applicable(DO NOT ABBREVIATE)

Percentage/

Grade Points

Registration /

Roll / Final

Year Seat

Number

Name of the

Degree

Awarded

(e.g.. B.com /

BA/ Mtech)

*Have you worked for IBM earlier? Yes No If "YES" , please provide following details:

Yes

Yes X No

Yes X No

Page 3 of 8, Employment App lic ation f orm V 02, wef - 11th May 2015

** IBM Corporation is an Equal Employment Opportunity Employer

EMPLOYEE NUMBER/

CONTRACTOR CODE

TYPE OF EMPLOYMENT

(Regular/FTH/Contractor)MANAGER'S NAME

LAST WORKING DAY

(DD-MMM-YYYY)

*Consistent with IBM's policy on workforc e diversity and in order to accommodate employee's special

needs in the work environment, please indicate if you are physically challenged

BUSINESS UNIT

DATE OF

JOINING

(DD-MMM-YYYY)

LOCATION

X

If yes, please indicate

your preferences

If yes, please provide description of disability and

accommodation / assistance required:

*Do you have any non-compete obligations or conf lict situ ations or other restri ctive clauses with any party

including any of your previous employers that prevent you from working for IBM India Private Limited?

No*Are yo u w il ling to r elocate as part of

your employment with IBM?X

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Organisation Name *Most Recent Start Date

Add ress along with PIN Co de End Date

Organisation Name Start Date


Organisation Name Start Date


Provide your last 3 (three) employment history. Also include information on self-employment. You can leave this page blank if you do not have prior work experience.

EMPLOYMENT HISTORY (FILL IN CAPITAL LETTERS)

Employee NumberFull Time / Part

Time

Serial

No

Employment Type

(Permanent

/Contractual)

TenureOrganisation Name and address

01

02

03

Organisation Name Complete Address

Contact Number


Contact Number


Contact Number

*Current Reportin g Manager will be cont acted ONLY AFTER the candidate join s IBM

Years MonthsTotal years of experience - (please do n ot in clude any

training or internship experience)

State GAP in

Employment if any:

01

Pin Code

02

Serial

No

Below is continuation of the above table. E.g. Continue to fill in details of "Serial No 1" (Above) in "Serial No 1-Continue" row below.

Reporting Manager's Name

and contact number)*

If Employment Type is Contractual, Please Provide Outsourc ing Agency Name, Complete

Add ress and Contact NumberDesignation

03

Reasons f or Leaving

Pin Code

Pin Code 009876533

Page 4 of 8, Employment Application form V 02, wef - 11th May 2015

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Last Name Middle Name First Name

Date of Birth Gender Nationality Passport No:

Father's Name IBM GOM Code / IBM Employ ee ID

Social Security # / National Insurance # Proof of name change attached if applicable Yes X No

EDUCATION (Please mention only highest completed education as declared in Employment Application Form)

Name of Degree / Diploma

Note : If you are a Fresher, please specify " NA" in all the fields below.

From Job Title

To Employee ID :

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY,

GOTHAPATNA ,BHUBANESWARYear of

passing

NA

NA

BACKGROUND CHECK APPLICATION FORM - I

SATAPATHY

From MMM / YYYY To MMM / YYYY

ANSUMAN

M0986363INDIAN

*Name & Location of School/College/Institute

(also mention whether course attended is

Regular/correspondence)

13/10/1993 MALE

ASHOK KUMAR SATAPATHY GBS-A36895453-17837906

B.TECH

Roll Number / Registration Number / Exam Seat

Number

Also in dic ate Spec iali zatio n of the Deg ree

Di l om aELECTRONICS AND ELECTRICAL ENGG. (EEE)

Name & Location of univ ersity to which t he

college/Institute is affiliated to

MayDates

attended Sep

From MMM / YYYY

2016

May 2016

NA

EMPLOYMENT RECORD: Starting w ith your present or most recent employer, please list last 3 employments in chronological or der. When listi ng consul ting or temporary assignments under " Employer", state the

name of the consulting or temporary agency that placed you at the client sit e

B312007

NA

CURRENT / MOST

RECENT EMPLOYER

(Company Name)

NA

INTERNATIONAL INSTITUTE OF INFORMATION TECHNOLOGY,

GOTHAPATNA ,BHUBANESWAR REGULAR

2012

Employment s tatus (Permanent /Contractual)

OUTSOURCING AGENCY DETAILS

Pin code

From Job Title

To Employee ID

Employment s tatus (Permanent /Contractual)


Pin code


------------------

Complete Address

NA

NA

NA NAName

Full Address

NA

Complete Address NA

NA

NA

PREVIOUS EMPLOYER

(PRIOR TO THE MOST

RECENT (Company Name)

NA NA

NA

NA

Name

NA

NA

Full Address

Reason for

Leaving

NA

NA

NA

Reason for

Leaving :

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From Job Title

To Employee ID


Pin code


BACKGROUND CHECK APPLICATION FORM - I contd.

NA

NA NA

NA

NA

Name NA NA

Reason for

Leaving

*Date(DD-MMM-YYYY)

BHUBANESWARANSUMAN SATAPATHY

NA

Full Address

Complete Address NA Employment s tatus (Permanent /Contractual)

SECOND PREVIOUS

EMPLOYER (Company

Name)

NA

17-09-2015

INFORMATION RELEASE AUTHORIZATION ( TO BE SIGNED BY THE CANDIDATE)

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 investigations, any of this inf ormation is foun d to be incom plete or inaccurate, I understand that I will be subject to dismi ssal at any time during my employment. I hereby authorize IBM and /or any of its

subsidaries or affiliates, and any persons or organizations acting on its behalf to verify the information presented on this application form and to procure an investigative report or consumer report for that purpose. I

hereby grant authority for the bearer of this l etter to access or be provided with full details of my previous records.In addition, please provide any other pertinent information requested by the individuals presenting thi s authority. I hereby release from liability all persons or I authorize to contact my present employer

I have read, understand and by my sign ature consent to these statements.

NA

*Place*Signature Enter full name

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Last Name Middle Name First Name

Date of birth Gender Nationality

Father's Name Passport Number

ANSUMAN

INDIANMALE13/10/1993

Point of Reference# along with Contact details Point of Reference# along with Contact details

* House/Flat No. * House/Flat No.

NIT CAMPUS

L-202

BACKGROUND CHECK APPLICATION FORM - II

ASHOK KUMAR SATAPATHY M0986363

SATAPATHY

*PIN Code INDIA

BHUBANESWAR * State ODISHA

751003 *Country *PIN Code

CHILDREN PARK

Permanent Address (Please fill only if di fferent from the cur rent address)

ROURKELA * State

* Nearest LandMark

NALCO RESEARCH CENTRE

* City

* Street (Cross &

Main)

* Street (Cross &

Main)

IIIT BOYS HOSTEL

INDIA

GBS-A36895453-17837906

D/23

ODISHA

769008 *Country

* NearestLandMark

* City

IBM GOM

Code / IBM

Employee ID

*Current Address

Page 8 of 8, Employment App lication form V 02, wef - 11th May 2015

*Date

(DD-MMM-YYYY)

*SignatureEnter full name

INFORMATION RELEASE AUTHORIZATION ( TO BE SIGNED BY THE CANDIDATE)

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 inform ation may result in termination of

employment. If upon investigations, any of this information is found to be incompl ete or inaccurate, I understand that I wil l be subject to di smissal at any time during my employment. I herebyauthorize IBM and /or any of its subsidaries or affiliates, and any persons or o rganizations acting on its behalf to verify the information presented on this application form and to pro cure an

investigative report or consum er report for that purpose. I hereby grant authority for the bearer of this letter to access or be provi ded with full details of my previous records. In addition,

please provide any other pertinent information r equested by the individuals presenting this authority. I hereby release from liability all persons or I authorize to contact my present employer.

I have read, understand and by my signature co nsent to t hese statements.

ANSUMAN SATAPATHY

Name of the

contact person ABINASH MISHRA

*Place

Name of the contact

person ASHOK K UMAR SATAPATHY

9438575810

17-09-2015

Phone NumberPhone Number

* Present Address: Address where your are currently staying

** Permanent Address: Address w here you are permanently residing, i rrespective of Present address. This is ty pically your parents residence or an address in your home tow n.

# Reference: Could be your Parents, Spouse, Neighbours, Friends, Relatives, Room mate who stayed wit h you etc. or staying i n close neighborho od.

9668439164

BHUBANESWAR

An Suman

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