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( * represents compulsory fields )

Position applied for *
Department *
Job Opening (where seen)
Surname *
First Name (s) *
Home Address *
Zip/Postal Code : *
Telephone Number (Home) *
Telephone Number (Work)
E-mail Address *
Date of Birth    
Current or last salary
Minimum notice period
When would you be available to take up employment?

Starting with the most recent, please give details of your education and training (certificates will be required if you are called for interview).
Year of Passing Examination School/College/University % of marks/ Class/ Grade / Rank Principal Subjects

Special Courses / Training Attended:
 Duration   Organization / Institution Nature of Training Program Diploma / Certificate
(if any)
From To

Special Courses / Training Attended:
Please give details of all positions held since completing your full time education, starting with your most recent position. If you have no employment record, include details of any other work (E.g. voluntary work).

Date of Joining Employer's Name Position on Joining Present Position Reports to

Reasons for seeking change in Employment:

Job Description / Role & Responsibilities of the Present Job:

Previous Employment (start with your second last employment):
Period No of yrs Employer's Name Position held & Nature of work Total salary including all allowances, benefits & perks Reasons for leaving>
From To Starting Leaving

Have you worked for the Group before?      Yes    No
If so please state dates and Company /departments in which you worked, if not given above.

Have you ever been dismissed from a previous employment?      Yes    No
If yes, please give further details.

If you have answered yes to this question, the employer may be consulted about your employment record.

Is there any further information you would like to give in support of your application including interests outside of work? Please continue on a separate sheet if necessary.
Are you willing to be located anywhere in India: Yes / No. If no, preferred location :

Relatives / Friends employed in Samsara Group, if any:
Name Designation / Dept. Relationship Company / Location

Relatives / Friends employed in Shipping Industry, if any:
Name Designation / Dept. Relationship Company / Location

Family Background:
Name of the Family Member Relation Company/Location Designation/Dept.
(Please provide if employed)

Present & Expected Salary Package
(Please include all your benefits and perks, which you are getting in your present package under items heads listed below or specify in "Any Other" columns; if your item is not specifically listed).
    Present Expected
Per month Per year Per month Per year
1. Salaries & Allowances :
  ¤ Basic
  ¤ House Rent
  ¤ Conveyance
  ¤ Education
  Any Other Allowances / Reimbursements (please specify)        
2.     Contributions
  ¤ Provident Fund
  ¤ Superannuation
  Any other :
3. Other Annual Payments        
  ¤ Medical (Domiciliary)
  ¤ LTA
  ¤ Bonus / Ex-Gratia
  GRAND TOTAL (From 1 to 3)
4. Average per month (i.e. 1 to 3)
5.     Perquisites :        
  ¤ Telephone Reimbursement
  ¤ Company Car provided Yes / No If yes, specify make of the car :
  ¤ Driver's salary (in Rs.) Rs.  
  ¤ Car Maintenance / Patrol expenses limits / ceiling
6.     Flat / House Your own / Company provided

If staying in a Company provided house, please specify the following :
Name of the Building :   Locality  

No. of Bed Rooms :   Deposit lodged with the Flat Owner : Rs. 

Rent Payable : Rs  p.m

Lease period : From   To :   Renewable every : 11/12 months

Declaration : I hereby declare that all the details furnished in this form are true in every respect and I take full responsibility for the contents and consequences of this declaration.
Place   Date :