STRICTLY PRIVATE & CONFIDENTIAL

JOINING AND VERIFICATION FORM

It is the policy of the Company to conduct background checks on all candidates joining the Firm. All questions
in this application form must be typed out and sent to [email protected] before joining. This
form will help us put you in the system before you join. On the day of joining your single point of contact in
Human Resource Service will have printed this form and kept it ready for your signature. We will also use this
form for verifying your antecedents.

Please refer to the below list of documents of which you need to share a copy with us before 10 days of day of
joining. Pls send the scanned copy to the [email protected], and carry a set along with you
on your day of joining.

Documents Required
Academic *Final Year Marksheet
Check Provisional marksheet/ Degree certificate/ All semester marksheet

Releiving letter/ Releiving letter acceptance/ Service letter/ Experience letter

Employment
Appointment Letter
Check
3 Months salary slips
Deputation letter, if applicable

2 passport size color photographs

Address Proof (Electricity Bill/ Telephone Bill(BSNL)/ Ration Card/)
If rental then Leave and License Agreement/Affidavit (Period of Stay should be
Criminal Check mentioned in the below form )

Birth Proof (Passport/Driving License/Birth Certificate /10th mark sheet /Voter ID)

Professional
Name and contact numbers of the references (Blood relations contact details cannot be accepted )
reference
ID Check Passport/Pan card

Pan Card

4 passport size color photographs. Mail one soft copy of photo to

Mandatory for
[email protected]
system hiring
Original Cancelled Cheque of your bank account with your name, account number, NEFT, RTGS code
and IFSC code. If the cheque does not possess the above details, please give us the cancelled cheque
with a letter from the bank stating your name, account number, NEFT, RTGs code and IFSC code

Personal Details
Title: Mr / Mrs / Miss / Dr -

First Name: Last Name:

Place of Birth: Date of Birth: Gender: Female / Male

Passport No.: Nationality: Marital Status:

PAN No: Blood Group:

Permanent Address: Present Address:

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

 Pin Code:
Pin Code:
Telephone Number with STD
Mobile:
Code:
Emergency Contact
Name Address Telephone & Cell

Educational Institutions and Professional Bodies will be approached to verify your qualifications.
Please provide full and clear names and addresses for each institution attended. Indicate clearly your
qualifications and the exact name and address of any Qualifying body. Do not use abbreviated terms
or initials. On the day of joining, kindly provide a copy of your last mark sheet and degree certificate
for the highest qualification only. So please carry these with you.

Level of Education (Please list in descending order from the most recent)
Degree % or Student
University Name & Full Address Class From To
Diploma GPA Number

Professional Qualification if any over and above the qualifications stated above
Date of
Name & Address of Qualifying Body Professional Qualification
Qualification

Employment History

Please list previous employment in descending order from most recent position. Previous employers will be
contacted to verify your employment history. Provide full names, addresses and where possible, the
telephone number of each employer. Do not use initials or abbreviations. On the day of joining, kindly
provide either a copy of the appointment letter or experience letter or latest payslip for each
employment mentioned below. So please carry these with you. For the immediate previous
employment please provide the relieving letter or any such document that proves that you have been
relieved. So please carry these with you.

1 Company Name:

Company Address:

Country:

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

Telephone No.: Dates of Employment:

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

Last Remuneration Package Basic + Retrials: Allowances: Bonuses:

2 Company Name:
Company Address:

Country:

Telephone No.: Dates of Employment:

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

Last Remuneration Package Basic + Retirals: Allowances: Bonuses:

3 Company Name:

Company Address:

Country:

Telephone No.: Dates of Employment:

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

Last Remuneration Package Basic + Retirals: Allowances: Bonuses:

4 Company Name:

Company Address:

Country:

Telephone No.: Dates of Employment:

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

Last Remuneration Package Basic + Retirals: Allowances: Bonuses:

5 Company Name:
Company Address:

Country:

Telephone No.: Dates of Employment:

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

Last Remuneration Package Basic + Retirals: Allowances: Bonuses:

6 Company Name:

Company Address:

Country:

Telephone No.: Dates of Employment: From to

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

Last Remuneration Package Basic + Retirals: Allowances: Bonuses:

7 Company Name:

Company Address:

Country:

Telephone No.: Dates of Employment: From to

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

Last Remuneration Package Basic + Retirals: Allowances: Bonuses:

8 Company Name:

Company Address:

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

 Country:

Telephone No.: Dates of Employment: From to

Last Position Held: Manager’s Name:

Summary of Responsibilities:

Reasons for Leaving:

Last Remuneration Package Basic + Retirals: Allowances: Bonuses:

In case of insufficient space, please use the blank page at the end of this document. If you have a break in
employment of longer than 60 days during your period of employment , please explain in space provided
below.
There was a break of six months during March10-Sep10. As got shifted from Africa to India after
spending over five years, I wanted some time to settle down with my family before starting again.

Please answer the following questions truthfully (please circle):

1. Have you ever been refused entry into a foreign country? No / Yes
2. Have you ever been convicted in a Court of Law? No / Yes
3. Have you ever been declared bankrupt? No / Yes
4. Have you ever been suspended or dismissed by an employer? No / Yes
5. Do you have any relatives currently employed at Syngenta? No / Yes
Have you ever been disciplined or fined by any regulatory body, professional body or stock
6. No / Yes
exchange?
7. Have you ever been disqualified from acting as a Director of a company? No / Yes
Are you subject to any restrictive covenant or any other restriction with respect to
8. No / Yes
employment with Syngenta?

If you have answered “Yes” to any of the above questions, please explain:

Professional References: Please provide details of 3 references

Name Full Address Mobile and E-mail if any State How you
Landline Telephone know the
Contact reference

Declaration: I, _________________________________________ hereby authorise Syngenta or any of

its affiliates and any persons or organisations acting on its behalf to verify information presented in my
employment application and to procure an employment report or an investigative report for that purpose. I
understand that such a report may contain information about my background, character and personal
reputation. I further understand and agree that, in the event of my employment, an employment report or
investigative report may be procured in connection with subsequent employment decisions. Upon my written
request, I will be advised of the name and address of each employment reporting agency from which an
employment report or investigative report may have been obtained.

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

I also voluntarily authorise Matrix Business Services India Pvt Ltd to perform reference checks of my
employment (with the exception of my current employer) and such other checks and inquiries as are
necessary in order to verify information provided by me in my employment application. I hereby release from
liability all persons or entities requesting or supplying such information. I understand that my employment with
the Company may be terminated with immediate effect should any information provided herein be proven
untrue. I undertake to provide any documents that may be required for the verification and be present at such
offices to complete this procedure. Should I fail to do so by the time, I am due for confirmation, I agree that it
shall be construed that my verification has been unsuccessful

Signature Date

In order for the Company to obtain a complete and accurate background history, which may include
researching the credit histories of new employees, please list below your United States Social Security
Number (where applicable) and any other names (including maiden names) by which you have been
known. In addition, please provide all addresses at which you have resided during the past five (5) years,
which have not been mentioned above.

The below information will not be used to check your antecedents and are for purposes of records
only.

Mandatory Family Data (spouse & children for married persons only, Parent data for all employees)
First Name Last Name Birth Date Birth Place Nationality Gender Relationship
NEHA

Dependent Data
First Name Last Name Birth Date Birth Place Nationality Gender Relationship

Bank Details*
Bank Name Location of Branch Account Number

* Any declarations that you have to make for the purposes of income tax should be done on the day of
joining for which a separate declaration form will be given to you or you will be instructed to declare
the same through the employee self-service portal on-line.

Medical Insurance
Relationship
S. No. Name (In Capital Letters) Gender Date of Birth Age with
Location
Employee
1.
2.
3.

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

4.
Maximum 4 Members (Include Self, Spouse and 2 dependent children (Till 21 yrs. of Age) allowed. If
you want to cover parents please indicate below. Premium for coverage of parents will be deducted
from your salary. The quantum of deduction can be obtained from [email protected]
Relationshi
S. Gende Date of
Name (In Capital Letters) Age p with
No. r Birth Location
Employee
1.
2.
3.

Confirmation for Syngenta Code of Conduct

(This becomes applicable when you sign the form below – Please read the documents stated below)
I hereby acknowledge that I have been provided the documents on the following:
 Syngenta Code of Conduct
 Security Code of Practice on My Information Security Responsibilities
 Security Code of Practice on My Information Protection
I hereby confirm that I have read, understood the applicability and abide by the Syngenta Code of Conduct,
Security Code of Practice on information security responsibilities, Security Code of Practice on My Information
Protection and on the compliance helpline in respect of the code of conduct.

I undertake the responsibility to adopt/follow the Syngenta policies, procedures, guidelines, etc. In
case of any change in my particulars from this date, I will intimate to HR Administration immediately.

Signature Date

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

 Joining Report
(To be filled by the Recruiting Team on day of Joining)

Employee Name:

Department: Position:

GPS ID: Cost Centre:

Reporting Manager: Location of Work:

Work Level: Joining Date:

PF Number: EPS Number:

Date of Joining: Location of Joining:

Name of entity:

Signature HRBP Signature HRSBS:

Additional Information for Purpose of Visiting Cards only (if applicable)

Full Address of Entity:

Board Line Number: Fax Number:

DID Number: Official Cell Phone Number:

LR/APAC Regional Policy Guidelines/May 2009 – modified July 2012

 Syngenta Business Service
IS Services
INTERNAL USE ONLY

IT – User Account & Asset Requisition

Procedure:
1. Fill-in the space provided as complete as possible.
2. Department manager and HR manager’s signatures are required.
3. Submit the form to IS department 4 weeks in advance before the new user’s start date.
4. IS department will endorse the new account to the requestor within 4 weeks from the date of
receipt.
A. User Particulars For IS Dept
Use
Surname: First Name: Stamp Date
*Gender: MALE/FEMALE **Category: INTERNAL/EXTERNAL of Receipt
Job Title: Department:
Mobile Number: Location:
Company Name(If, EXTERNAL):
Budget Code (for Hardware –By HR):
If not Budgeted, provide justification:

Cost Center (By HR): Reporting To (By HR): Appointment Date:

GPS Employee Code (By HR): Date of Creation (By HR):

Unique Code (By HR):
B. Resource and Services required For IS Dept use
*Does user require standard Syngenta AD Account? YES / NO

*Does user required Syngenta Email account? YES / NO

*Does user require Remote Access? (GRAS) YES / NO
*Request for computer? Laptop/Desktop YES / NO
*Does user require Blackberry? (per policy only) YES / NO
*Does user require netconnect? (per policy only)
YES / NO If YES, please fill-up SAP User
*Does user require SAP account?
Application Form(via SMILE Tool)
Specify Distribution List (DL) to which users belongs:
Others Requirements/Comments:
Declaration: “as user of the blackberry connection now or in future, I declare and confirm that
Syngenta as my employer has provided me the connectivity of the Blackberry services on my
handset and in the event of my cessation of employment with Syngenta India Limited, I
acknowledge and confirm that Syngenta India Limited and all persons acting for and on behalf are
authorized to disconnect the said services and connectivity on my handset and I further
acknowledge the fact that in the process of disconnecting the services and connectivity my personal
data on the Blackberry handset would also get deleted and with respect to which I do not have any
sort of objection or complain.”

Signature of User Date:

C. For Official Use Signature Date
Department Manager:
Human Resource:
IS Manager:

*Delete or strike-through as appropriate.

**Internal denotes Syngenta employee. External denotes 3rd party.
 FORM - 2 (REVISED)

NOMINATION AND DECLARATION FORM

FOR UNEXEMPTED / EXEMPTED ESABLISHMENTS

Declaration and Nomination form under the Employees' Provident Fund and Employees'
Family Pension scheme

(Paragraph 33 and 61(1) of the Employees' Provident Fund Scheme, 1952 and Paragraph 13 of the
Employees' Family Pension Scheme, 71)

1. Name (in block letters) :

2. Date of Birth :

3. Account No. :

PART - A (EPF)

I hereby nominate the person(s) / cancel the nomination made by me previously and
nominate the person(s), mentioned below to receive the amount standing to my credit in the
Employees' Provident Fund in the event of my death:

Name of the Address Nominee's Age of Total amount If the nominee is a

nominee / relationship with nominee(s) of share of minor, name and
nominees the member accumulations address of the
in Provident guardian who may
Fund to be receive the amount
paid to each during the minority
nominee of nominee
(1) (2) (3) (4) (5) (6)

1. *Certified that I have no family as defined in para 2(g) of the Employees' Provident Fund
Scheme, 1952 and should I acquire a family hereafter the above nomination should be
deemed as cancelled.
2. *Certified that my father / mother is /are dependent upon me.

*Strike out whichever is not applicable.

Signature / or thump impression of the subscriber

_______________________________________________________________________________
 2

PART - B (EPF)

I hereby furnish below particulars of the members of my family, who would be eligible to
receive Family Pension & Life Assurance benefits in the event of my premature death in service.

S. No. Name and address of the family member Age Relationship with
the Name Address member
(1) (2) (3) (4) (5)
1.
2.
3.
4.

*Certified that I have no family as defined in para 2(b) of the Employees' Family Pension Scheme,
1971 and should I acquire a family hereafter I shall furnish particulars thereon in the above form.

Date:
*Strike out whichever is not applicable Signature or thumb impression of the
subscriber.

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed
before me by Shri/Smt./Kum. employed in my
establishment after he/she has read the entries/the entries have been read over to him/her by me
and got confirmed by him/her

Signature of the employer or other authorized

Officer of the establishment

Place: Designation:
Dated the: Name and address of the Factory/establishment
or rubber stamp thereof.
 3

Note: WHOM YOU CAN NOMINATE

(A) UNDER THE EMPLOYEES’ PROVIDENT FUND SCHEME

(1) A member of Employees’ Provident Fund who is married and / or his father/ mother
is /are dependent upon him can nominate only one or more persons belonging to his
family as defined below:
(a) In the case of a male member, his wife, his children, his dependent parents and his
deceased son’s widow and children;
(b) In the case of a female member, her husband, her children, her dependent parents,
her husband’s dependent parents, her deceased son’s widow and children.
(2) If the member has got no family, or is a bachelor nomination may be in favour of any
person or persons, whether related to him or not or even to an institution. If the
member subsequently acquires a family, such nomination shall forthwith become
invalid and the member should make a fresh nomination in favour of one or more
persons belonging to his family.

(B) UNDER THE FAMILY PENSION SCHEME :

(1) On the death of a Member of the Family Pension Scheme, his family will be entitled to
the benefits under the Family Pension Scheme. The family is defined as under :-

(a) Wife in the case of a male member;

(b) Husband in the case of a female member ; and
(c) Minor sons and unmarried daughters.

Explanation: The expression “sons” and “daughters” shall include children adopted
legally before death in service.

(2) If the member has got no family, the monthly family pension, on the death of the
member, will not be paid. However, Life Assurance Benefit will be paid to the person
or persons entitled to receive his provident fund accumulations.
 4

ANNEXURE ‘E’

APPLICATION FORM FOR VOLUNTARY CONTRIBUTION

(See Rule 11(b)

Date of Application

1. Name of the employee

2. Department / Section

3. Account Number, if any

Ledger Folio No

4. Present Rate

a) Basic Pay
b) Dearness Allowance

5. Present rate of contribution

6. Proposed rate of contribution

7. Difference on account of Voluntary Contribution

8. Date from which such contribution is proposed to be made

9. Address

Signature / Thumb Expression

Voluntary contribution @ % permitted.

 FORM OF NOMINATION

The Trustees,
Syngenta Employees’ Gratuity Trust Fund
Pune

Dear Sirs,
I, Mr. /Ms. a member of Syngenta
Employees’ Gratuity Trust Fund hereby agree to abide by the said Scheme and do also hereby
appoint in terms of Rule 16 of the Rules, Beneficiary/ies Nominee/s mentioned hereunder to
receive the benefits, payable under the Scheme, in the event of my death.

I hereby direct that the benefits under the Scheme, payable in respect of me, shall be paid to the
said Beneficiary/ies Nominee/s in proportion indicated against their respective names as given
below.

Sr. Name in full with address of Relationship Age of ***Proportion Name of the
No Nominee/s Benficiary/ies with the Nominee/ by which Person to
Member s Gratuity receive
(Should be a /Benefici (Total payment in
member of ary/ies Benefits) will case of
the family** be shared by Beneficiary
each being in Minor
Nominee/
Beneficiary
1.

2.

*1. Certified that I have no family and should I acquire a family hereafter, the above
nomination should be deemed as cancelled.
*2. Certified that my father / Mother / Sister (s) / Minor Brother (s) is / are dependent upon me.

I give below the particulars about myself:

1. Name (in Full):
2. Gender:
3. Religion:
4. Father’s Name:
5. Husband’s Name:
6. Marital Status: Married/ Unmarried / Widow/ Widower
7. Date of Birth:
8. Permanent Address:
 State: Pin Code:

Date:
Signature of Member

Two witnesses to sign

1.

Name, Signature & Address of Witness

2.

Name, Signature & Address of Witness

Certified that the above declaration has been signed by Shri/Shrimati

before me after he/she
has read the entries / the entries have been read over to him / her by me.

Date:
Signature of the Trustee or any
Person authorized by the Trustees in
this behalf