Application Cum / Personal Particulars Form for

Character Verification

1) Name in Full (in Block Letters): 2) Present Address in Full: 3) Duration at Present Address: 4) Jurisdiction of Police Station: 5) Home address in Full: 6) Jurisdiction of Police Station: 7) Applicants Date of Birth: 8) Place of Birth: 9) Present Age: 10) Particulars of Places (with period of residence): From To

Where you have resident during recent years since birth 1) 2) 11) Information

Name
Father Mother Husband/Wife

Occupation Address

with

Present Address

Brother

Sister Any Other Friends

12) Applicants Education Qualification: Name & Address of School & College Date of Joining Date of Leaving Examination

13) How ever been arrested /Prosecuted / detailed If so give particulars of Case. 14) Have you ever active taken in politics if so Give Particulars. 15) Present Occupation / Service with all particulars 16) Purpose for requiring this Character / Antecedence Verification Certificate (To whom it is required) 17) Identification Mark (Visible) 18) Name & Addresses of two prominent persons in your locality who know you 1) 2) 19) I here by solemnly state that, the information provided by me is true. Signature of Applicant

Note: Applicants to attach the following documents with this application. 1) 2) 3) 4) Two Passport Size Photographs. Xerox copy of Ration cards showing applicants Name and Address. Xerox copy of the School Leaving Certificate. Xerox copy of the Passport/ Driving License / Election Card.