Employment Application Form

Please affix your passport size photo here

Please read the below instructions carefully before you start filling in the requested information:

1) Please read all instructions for each section and fill in as instructed. All fields are to be filled legibly, completely and accurately in CAPITAL letters to reduce delay in processing your candidature with IBM. 2) Please bring the following documents with you to the personal interview at IBM: i) Completed IBM Employment Application Form ii) Proof of Salary Documents Offer letter with compensation break up OR Latest increment letter from present organization with compensation break-up iii) Updated Resume iv) Valid Photo ID (Passport, PAN Card, Voters ID card, Drivers License)
Past IBM Interview Details (Fill in CAPITAL Letters) Have you attended any IBM Interview in the last 3 Months If Yes, please provide the below details:
D D M M M Y Y Y Y

Yes

X No

Date of Interview Position Applied

Work in Progress

Received Offer

Rejected/Declined

Location Of Interview
IBM subsidiary Name IBM India Pvt Ltd IBM Daksh IBM NetSol
1

Page 1 of 6, Employment Application form, version 4.0, wef - 05th Mar 2012

SOURCE INFORMATION (Fill in CAPITAL Letters)

How did you know about this vacancy in IBM? (Select any one of the below)
Direct - IBM Website

Agency Agency name

X
U S

IBM Employee Referral

Accepted Not Joined Candidate

Name of the Employee

D R

A I

Y R A M O J U

Employee Number (If Applicable) Jobsites Job Site Name E- Mail ID

It is important that you mention the employee ID or Email ID accurately, please confirm with the referrer if you are not sure of the information

By submitting the IBM Employee Referral name you confirm that the referrer is known to you personally or professionally. This relationship may be a result on account of participation in various social networks which are either formal (examples of formal networks are Linkedin, Facebook, Twitter, industry and competency associations) or informal (examples of informal networks are former employment with the same company, friends circle, alumni from same educational institution or study circles) . You also confirm that the referrer has made you aware that by referring your candidature to IBM for an opportunity of employment, he/she may be eligible to receive a referral bonus.

IBM Application ID *

* If you have already registered on our IBM Job Portal please provide the IBM Candidate Applicant ID also called GOM Candidate Applicant ID. If you are referred by an Agency, please ask your agency for the Applicant ID

PERSONAL INFORMATION (Fill in CAPITAL Letters) * Enter your name as per your Passport, Driver's Licence OR PAN Card (For Indian Nationals)
Title

X Mr.
First Name B H A S

Ms.

Middle Name

Last Name D A S A D Date of Birth R D I M M M Y Y Y Y

**e.g. 01 - JAN - 1900

Mobile Number

8
-

**Country code - Mobile Number Telephone

**Country code - City Code - Telephone Number Personal Email ID

b b

a u

c d

h d A

i y L D

s 4 M L

a 8 P F

i 4 D A

2 8 1 P

0 1 6 1

1 @ 4 0

2 g 7 1

@ m H 8

g a

m i

a l

i .

l c

. o

c m

Pan Card

(If you are an Indian National)

Driver's Licence #

7
D

2
D

0
M

8
M M Y Y Y Y

Passport Number

7
H

2
Y

0
D

4
E

1
R A B A D

Expiry

Place of Issue

Refer to the passport for this information

Page 2 of 6, Employment Application form, version 4.0, wef - 05th Mar 2012 2

PERSONAL INFORMATION CONTINUED (Fill in CAPITAL Letters)

Nationality

INDIAN
M A N D A M A R R I

City of Birth

Country of Birth

Current Address #21 GOWTHAMA GIRI NILAYA , 1ST MAIN ROAD , 1ST CROSS , NARAYANAPPA LAYOUT , ALLALASANDRA , GKVK POST.

City State

BANGALORE
KARNATAKA

PIN Code

560065

Country INDIA Permanent Address (If different from the above) H.NO : 42-60/A , MARUTHINAGAR , MANDAMARRI , ADILABAD (DIST)

City State

MANDAMARRI
ANDHRA PRADESH

PIN Code

504231

Country INDIA

PROFESSIONAL REFERENCES (Fill in CAPITAL Letters)

Please provide details of three professional references with whom you have had a business/Working relationship of which one reference has to be mandatorily your previous Manager's details Please exclude Friends, Colleagues, Juniors, Relatives at work and Clients
Name SRIDHER K Contact Number 9845188698 Nature of professional Relationship Current occupation Comments*

PROJECT MANAGER PROJECT MANAGER PROJECT MANAGER IN INTEGRA MICRO SOFTWARE SERVICES PVT LTD AT & T ACCOUNT ASSOCIATE SYSTEM ASSOCIATE SYSTEM ENGINEER ENGINEER IN IBM HYDERABAD

DILIP KOSURI

9959639937

SUDESHNA VUSTIPALLI

9962078674

AT & T ACCOUNT

SENIOR SYSTEM ENGINEER

SENIOR SYSTEM ENGINEER IN IBM CHENNAI

*Please use the comments column to indicate if you do not wish IBM to contact one or any of the above for pre-reference checks.

Page 3 of 6, Employment Application form, version 4.0, wef - 05th Mar 2012

EDUCATION DETAILS (Fill in CAPITAL Letters) Please complete all fields, even if you have already provided a resume. Provide details on COMPLETED degree programs only.
Highest Qualification (Completed)** e.g.: M.Sc, B.Com B.Tech

PLEASE MENTION COMPLETE DETAILS OF SCHOOL / COLLEGE / INSTITUTION AND UNIVERSITY NAME ALONG WITH COMPLETE ADDRESS WITH CITY & POSTAL CODE IN CAPITAL LETTERS Name of the Class/ Degree Complete Name & Address of School / College / Institution and Division/ Qualification Course Tenure Awarded Name of the University Percentage/ (e.g.. B.com / *University name is mandatory where applicable(DO NOT ABBREVIATE) Grade Points BA/ Mtech)

SSLC ( 10th)

Start Date End Date

M M M

M A A

M R R

Y 9 0

Y 9 0

T L D A S L D A J A R E

A I N R L I N I N E R

W R S D A E S D T D C A

A A T H V G T H S H O B

K M R R A E R R R G A

K A I A N I A K A N D

A K C P T D C P A P I

L R T R H H T R R R S I : A I A : A I A E

H S A D R W D M D D

I H D E J M A E N E

G N I S U A R S A S J

H A L H N R A H G H N T A I A N P A

S U B O M G R U

C R A R A

H D

O 66.6

SECONDARY SCHOOL CERTIFICAT E

* E.g. JAN09 Start Date End Date M M M M A A M R R Y 0 0 Y 0 2

C L

O 77.4 INTERMEDIA TE

HSLC (12th)

* E.g. JAN09 M A A M P P M R R Y 0 0 Y 3 7

Graduation

Start Date End Date

62.82

B.Tech

* E.g. JAN09

University Name

M
Post Graduation

Start Date End Date * E.g. JAN09

University Name

M
Others - PhD, Start Date Additional Degrees

End Date

* E.g. JAN09 M Start Date End Date M M Y Y

University Name

Professional Qualification (Other than already mentioned above) like CA, CFA etc

* E.g. JAN09 State reasons for GAP in education, if any : Professional Training (includes in progress degrees) - please mention the details ______________________________________________________________________________________________________________________________________________ Page 4 of 6, Employment Application form, version 4.0, wef - 05th Mar 2012

EMPLOYMENT HISTORY (Fill in CAPITAL Letters)

Provide your job history for a minimum of the last five (5) years (if applicable). Additionally, include your last three 3 employers (if applicable) even if your total service exceeds 5 years in the last 1 or 2 companies. Please include information on Self employment within the same period.
Do you have prior employment experience?

Yes

No

Serial No
Organisation Name Address

PLEASE MENTION COMPLETE DETAILS OF ORGANISATION NAME, COMPLETE ADDRESS WITH STREET NAME, AREA, CITY & POSTAL CODE IN CAPITAL LETTERS Employment Type (Permanent Organisation Name and address /Contractual) and Tenure Band / Grade details N T E G R A M I C R O S O F T W A R E M M M Y Y D D S E R R N M C N B A S R T H Y A Y L H A N A T Y D V O I D I A A E I T G M D D E P N H A U F A L C H R O O I A T O E S T R M T B D Y E E P E A U C D T H A S C T T H C D E S 1 2 P T V H T K L M T D B 5 U A 6 G P K 5 S I D T H 5 6 E Y R 0 A 0 4 N 0 H V N 0 R T A 0 V M P 0 G 4 I A R 8 B G 0 E A 6 A L L 4 R L A 5 C D A 1 Start Date End Date D D CONTRACT Start Date End Date D D PERMANENT Start Date End Date * E.g. 01-JAN-1900 M M M Y Y

Employee Number

Full Time / Part Time

1 L O L R A E I T M R A S E P S U H R

12390

Full Time

Y I B E A

Pin Code H E P R M A O S R

Organisation Name Address

2 T W D A

0 0

5 5

A A
M

P U
M

R G
M

1 1
Y

0 1
Y

AVA4XN

Part Time

Pin Code E R C N

* E.g. 01-JAN-1900

Organisation Name Address

3 H D A E

2 0

3 8

J M

U A

L Y

0 0

7 9

64349

Full Time

Pin Code

* E.g. 01-JAN-1900

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.
Serial No Designation Reasons for Leaving Reporting Manager's Name and contact number)* If Employment Type is Contractual, Please Provide Agency Name, COMPLETE Address and Contact Number

Organisation Name Complete Address

1Continue

SENIOR SOFTWARE ENGINEER

RESIGNATION

9845188698

Pin Code Organisation Name Complete Address

Contact Number

R L

T T C

E D I N 0 1

H C Y

I B P L 0 O

N E H R

F R A E

S P

Y A I

S R

T K P

M S E L E

T R 7 6

C T

2Continue

SOFTWARE ENGINEER

RESIGNATION

9986171290

O -

N 7

I 7

C B 5 6

T G 0

Y A

O T

N O

Pin Code Organisation Name Complete Address

Contact Number

3Continue

SOFTWARE ENGINEER

RESIGNATION

8880180552

Pin Code

Contact Number

*Current Reporting Manager will be contacted ONLY AFTER the candidate joins IBM

0 4 Years 0 2 Months Total years of experience - (please do not include any training or internship experience) State GAP in Employment if any: GAP BETWEEN JUNE 2009 TO MAR 2010 DUE TO RECESION IN SATYAM COMPUTERS PVT LTD
Page 5 of 6, Employment Application form, version 4.0, wef - 05th Mar 2012 5

Present Employment Compensation Details** (Fill in CAPITAL Letters)

** The information stated here must be supported with documentary evidence (Offer letter from present organization including Compensation break up details or most recent increment letter) Please mention below your annual compensation details (A). Fixed Pay including statutory benefits (Rs.) (B).Variable Pay (Rs.) (C). Other allowances (Rs.)

Annual Current CTC = Total of A + B + C (Rs.)

Comments

OTHER DETAILS (Fill in CAPITAL Letters)

Have you worked for IBM earlier? If "YES", please provide following details:
Tenure (DD-MMM-YYYY) Business Unit Location Date of Joining Last working day Manager's Name Status (Regular/FTH/Contractor) Employee No. / Contractor Code

X Yes

No

SNMS CLUSTER

BANGALORE MANYATHA

04-May-2010

08-May-2011

SUDHARSHAN SETHI

CONTRACT

AVA4XN

Are you willing to relocate as part of your employment with IBM?

If "YES", please indicate your preference

X Yes

No

_______________________________________________________________________

If you are related to IBM India Private Limited employees and/or Directors (sibling / spouse/ children/in law relationships), please provide names and relationship. Name Designation Business Unit Relationship

Consistent with IBM's policy on workforce diversity and in order to accommodate employee's special needs in the work environment, please indicate if you are physically challenged ** ** IBM Corporation is an Equal Employment Opportunity Employer Do you have any non-compete obligations or conflict situations or other restrictive clauses with any party including any of your previous employers that prevent you from working for IBM India Private Limited? Yes Yes

X No

If yes, please provide description of disability and accommodation required:

X No

X No Have you worked for the Government, whether as a civilian employee or member of the military? Yes All Candidates must indicate if they have worked for the Government, whether as a civilian employee or member of the military. If so, you must also indicate whether you had any responsibilities or were involved in activities relating to IBM or an affiliated Company. You must also state whether you are aware of any legal restrictions on what work you may do for IBM or an affiliated Company, and if so, what those restrictions are.
Name of Government Organization and Department Tenure Job Responsibilities Restictions ( if any)

Declaration
If applicable, I hereby confirm that in my duties as a government employee, I have (or have had) no matters involving IBM (in any capacity whatsoever), or if I do, that I have officially withdrawn from participating in those matters while I am discussing potential employment with IBM. All details of any such matters that I have been involved with, where IBM or any of its affiliates have been involved, are listed above. I confirm that the information provided by me in this application form is complete and accurate. I understand that if any information provided by me with respect to my application for employment is found to be untrue, inaccurate or misleading, IBM INDIA Private Limited may withdraw any offer of employment made to me or terminate my employment (If I have already joined IBM India) without notice. I understand that all the details provided in this application are subject to verification. I hereby authorize IBM India Private Limited and its representatives (including reference check agencies/third party vendors) to verify information provided in my application for employment and to conduct enquiries as deemed necessary by the company. I authorize all persons who have information regarding my education, employment, and all other details provided in this form, to disclose it to IBM or its representative.

Signature:

BHASKAR DASARI

Place:

BANGALORE

Date:

27-06-2012

Page 6 of 6, Employment Application form, version 4.0, wef - 05th Mar 2012