4：《背景核实信息表》及《个人信息查询及披露授权确认书》.doc

Background Screening Information Form背景核实信息表for上海银行Important Notice / 重要声明:1. All question fields in this information form must be completed and answered correctly.此信息表中所有的问题需全部完成并准确回答。2. First Advantage will not contact the current employer if its stated not to contact now. Please provide a suitable contact date which should not be later than your onboard date.如果已声明目前不可以联系当前雇主，首优咨询有限公司不会与该雇主联系。但请提供不晚于您新公司入职日期的联系日。3. First Advantage does not commit to only contact the provided contact person for background screening. The provided contact will be used as a reference.首优咨询有限公司并不承诺只会与所提供的联系人完成背景核实。所提供的信息将作为参考。4. If you would like First Advantage to only contact the provided contact person, please state the request on the information form. First Advantage will confirm with its client before making the contact.如果您希望首优咨询有限公司只与您提供的联系人完成背景核实，请将具体需求写明在信息表中。首优咨询有限公司会先与客户确认后再决定是否可行。5. All information provided are for background screening purpose only and kept in confidential.所有提供的信息仅供背景核实使用且严格保密。6. Once Background Screening is completed, the report will be returned to the HR team for recording.在背景核实完成后，相关报告会交至人力资源部门存档。Personal Information:个人信息Please give full details of your name and alternatives used where applicable. Known as name should be provided where appropriate. 请提供您的全称及其他曾用名（如适用）。Family Name(Surname):姓Given Name(First_Middle_etc.):名English Name / Other Name英文名 / 曾用名Name in other Language(i.e. in Chinese, Japanese etc. characters / Alias, if any) :中文全名王菲菲王菲菲Date of Birth(Date/Month/Year):出生日期Gender(Male/Female) :性别Cell Phone Number:手机号码Current Email Address现常用邮箱地址17/05/1986 Male (男) Female (女Identity Card No.证件号码Country of Issue(Identity Card)颁发国家Types of Identity(Identity card/Passport)证件类型Nationality国国 Identity Card (身份证) Passport (护照)中国* If you have secondary nationality or more, please also provide the Identity Information如果您有其他国籍，请同样提供相关信息* Secondary Identity Card No.第二证件号码* Country of Issue (Identity Card)颁发国家* Types of Identity(Identity card/Passport)证件类型* Nationality国籍 Identity Card (身份证) Passport (护照)In order for the Company to obtain a complete and accurate background history please provide full details below.为便于取得完整并准确的背景历史，请详细填写以下资料。Have you lived or worked in the United States during the past 7 years? If yes, Please provide your US Social Security Number, and if no, please indicate “no” in the space provided:您是否在过去7年中在美国居住或工作过？如果是，请提供您的美国社会保险号。如果是否，请在右侧空白处写”No”US SSN:NoHave you lived or worked in Canada during the past 7 years? If yes, Please provide your Canadian Social Insurance Number, and if no, please indicate “no” in the space provided:您是否在过去7年中在加拿大居住或工作过？如果是，请提供您的加拿大社会保险号。如果是否，请在右侧空白处写”No”Canadian SIN:NoResidential Address(es) (please provide all addresses in full indicating clearly Street Name/Number, Country, State & City) : at which you have resided during the past five (5) years, commencing with your current residence. Please indicate the residential period for each address.居住地址：请将您在过去5年间曾居住超过6个月的详细地址列出，包括您现在的居住地址。S/NAddress (In descending order, 1 being the most current residential address)地址(按时间顺序倒叙，第一行为最近居住地址)Period of Stay (Years)居住时间 (年)1上海市普陀区靖边路199弄39号1004室1.52上海市虹口区东体育会路475号13上海市徐汇区梅陇路130号345For candidates from Peoples Republic of China, please complete below details:中国籍候选人，请填写以下信息。Hukou Address(户籍所在地址)上海市普陀区靖边路199弄39号1004室Hukou Type(户口类型) Individual Hukou (个人户口) Collective Hukou (集体户口)Police Station(户籍管辖派出所)上海市普陀区桃浦派出所Entity that holds the official HR file and file number(人事档案所在单位包括单位名称，地址，电话和存档号)档案所在单位： 上海宝信软件股份有限公司档案保管单位地址：上海市浦东新区郭守敬路515号联系人：朱菁菁联系电话：20378827存档号：178571For PRC Candidates: Please attach a copy of your PRC ID card中国大陆籍候选人：请附上身份证复印件For Other Candidates: Please attach a legible copy of your passport which was used when travelling to China非中国大陆籍候选人：请附上护照复印件Educational Qualifications:教育经历Educational institutions will be approached to verify your qualifications. Indicate the exact name under which any education qualifications were attained. Please provide full and clear names and addresses for each institution attended. Do not use abbreviated terms or initials.教育院校将会被联系以便求证您的教育经历。请提供完整并准确的教育类证书名称，院校名称及地址。请不要使用缩写或简写。If you dont have any tertiary academic award, please check this box: 如果您没有任何高等教育经历证书，请勾选此框Please attach copies of your Diploma & Degree Certificates and if the institution is outside of China and authenticated by the Overseas Study Service Centre of Ministry of Education of China, please provide copy of the Authentication Certificate.请附上毕业证书及学位证书复印件。若该院校在国外并已在中国教育部留学服务中心认证，请也提供认证书复印件。School Name (University/College) :学校名称华东理工大学Address (indicate clearly Street Name/Number, Country, State & City):学校地址梅陇路130号上海 中国Telephone No.:电话号码-2164253035Qualification Awarded:获得学位 Diploma (大专) Certificate of Completion (结业) Undergraduate Diploma (本科毕业-无学位) Bachelor (学士) Master (硕士) PhD (博士) Pursuing Study (在读) Others (其他)If others, pls specify (其他 请提供): Level of Study学制 Regular Study (普通高教) Adult Study (成人高教) Top Up Study (专升本) Self Study (自学考试)Student/ Roll No. (where applicable):学号(如适用)Year of Study(month/year)就学时间From:从09/2009To:至03/2012Is this qualification archived from outside of PRC?所取得的学历学位是从中国大陆境外获得的吗？ Yes (是) Has this certificate been authenticated by the Overseas Study Service Centre of Ministry of Education of China? (若是，这个证书被中国教育部留学服务中心认证过？)Yes please provide the copy of Overseas Educational Qualification Authentication Certificate. (有 - 请提供中国教育部留学服务中心的国外学历学位认证书复印件)No (没有) No (不是)Employment History:工作经历If you do not have any working experience, please check this box: 如果您没有任何工作经历，请勾选此框Please state your current or most recent employment. The employer will be contacted to verify your employment history. Provide full names, addresses and, where possible, the telephone number of the employer. Do not use initials or abbreviations. 请提供您当前或者最近的雇用经历。此雇主将会被联系以便求证于您的雇佣经历。请提供公司全称，地址以及，如可能，此雇主的联系电话。请不要使用缩写或简写。1.Company Name:公司名称上海宝信软件股份有限公司Company Address(indicate clearly City and Country):公司地址（请确保提供城市及国家）Address (地址): 郭守敬路515号City (城市): 上海Country (国家): 中国Branch / Department:就职部门大数据事业部HR Information:人事部信息Name:姓名李翔Contact Detail:联系电话及邮箱Phone Number (联系电话): 50801155-2274Email Address (邮箱): Line Manager Information:主管信息Name:姓名殷峻Job Title:职位部门总监Contact Detail:联系电话及邮箱Phone Number (联系电话):mail Address (邮箱): Dates of Employment:就职时间From (Month/Year):从 (月/年)05/2012To (Month/Year):至 (月/年)03/2015Last Position / Designation:职位工程师Employee ID:员工号178571Reason for Leaving: 离职原因改变业务领域和工作环境Last Remuneration Package离职前薪酬Basic Salary:月薪Allowances:补贴Bonuses:奖金Currency币种人民币720010004000Status ( appropriate box):雇佣类别 Permanent (正式员工) Contractor (合同制员工) Temporary (临时员工) Volunteer (志愿者) Intern (实习生) Partime (兼职员工) Others (其他)If others, pls specify (其他 请提供): * Please complete below if you were employed through an agency 如果您是以劳动派遣方式被此雇主雇佣，请完成下列问题* Name of Agency: 派遣机构* Agency Contact Person: 派遣机构联系人* Telephone No.: 派遣机构联系电话Can we contact this employer immediately to conduct a Background Screening now? (Please ):我们现在能否立即与此雇主联系并开展背景调查 (请选择) Yes (可以) No (不可以)If no, please specify the earliest date we can contact this employer to complete a Background Screening如否，请提供最早我们可以与此雇主核实的日期 16/03/2015 (DD/MM/YYYY)Please state your pervious employments in descending order. 请倒叙提供您之前的雇用经历。2.Company Name:公司名称Company Address(indicate clearly City and Country):公司地址（请确保提供城市及国家）Address (地址): City (城市): Country (国家): Branch / Department:就职部门HR Information:人事部信息Name:姓名Contact Detail:联系电话及邮箱Phone Number (联系电话): Email Address (邮箱): Line Manager Information:主管信息Name:姓名Job Title:职位Contact Detail:联系电话及邮箱Phone Number (联系电话): Email Address (邮箱): Dates of Employment:就职时间From (Month/Year):从 (月/年)To (Month/Year):至 (月/年)Last Position / Designation:职位Employee ID:员工号Reason for Leaving: 离职原因Last Remuneration Package离职前薪酬Basic Salary:月薪Allowances:补贴Bonuses:奖金Currency币种Status ( appropriate box):雇佣类别 Permanent (正式员工) Contractor (合同制员工) Temporary (临时员工) Volunteer (志愿者) Intern (实习生) Partime (兼职员工) Others (其他)If others, pls specify (其他 请提供): * Please complete below if you were employed through an agency 如果您是以劳动派遣方式被此雇主雇佣，请完成下列问题* Name of Agency: 派遣机构* Agency Contact Person: 派遣机构联系人* Telephone No.: 派遣机构联系电话Can we contact this employer immediately to conduct a Background Screening now? (Please ):我们现在能否立即与此雇主联系并开展背景调查 (请选择) Yes (可以) No (不可以)If no, please specify the earliest date we can contact this employer to complete a Background Screening如否，请提供最早我们可以与此雇主核实的日期 (DD/MM/YYYY)Please use blank paper to provide details of additional employers, if necessary.如您还有额外的雇用经历需要补充，请另附纸张。Are you currently engaged in any other business either as a proprietor, partner, officer, director, trustee, employee, agent or otherwise? (您目前在其它单位担任任何职务，如所有人，股东，政府官员，企业董事，企业托管人，雇员，代理或其它职务吗？) No (否) Yes (是)If yes, please give details. (如回答是，请具体说明。)Have you ever been arrested for or convicted of a criminal offence? (您是否被拘留过，或曾经被判有罪？) No (否) Yes (是)If yes, please give details. (如回答是，请具体说明。)Do you know or are you related to anyone who works for the company?(您是否与目前申请的公司的员工认识或有关系？) No (否) Yes (是)If yes, please give details. (如回答是，请具体说明。)Declaration声明I hereby certify all of the statements made on the employment application form are true and complete and I understand that omission or misrepresentation of any fact may result in refusal of employment or immediate dismissal.本人在此保证，本人在此职位申请表中填写的所有情况均属实和完整。由情况遗漏或失实可能导致的申请被拒绝，本人表示理解。I recognize that in connection with employment with Bank of Shanghai . I may be the subject of a background enquiry by Bank of Shanghai and I hereby authorize the same. 本人清楚并认可，在向上海银行 申请职位的过程中，本人可能成为相关背景核实的调查对象。Signature(签名) :Date (dd/mm/yy)(日期) :Letter of AuthorizationTo Whom It May ConcernI hereby autho