POLICE CLEARANCE CERTIFICATE APPLICATION FORM

To
The Superintendent of Police,
District Police Office,
_________________.
Applicant must paste
one photograph 35mm
Subject: Application for issuance of PCC x 35mm here with half
the signature on the
photograph and half on
Sir, the application
It is requested that a Police Clearance Certificate
may be issued to me for visa/immigration purpose. My
personal particulars are as follows:
Full Name (Expanded Initials) ________________________________________

Sex _______________________________________________________________

Previous Name (in case the name has been changed)________________________________

Date of Birth _______________________________________________________

Occupation ________________________________________________________

Father (Full Name) ___________________________________________________

Mother (Full Name) __________________________________________________

Spouse (Full Name) __________________________________________________

Permanent Address __________________________________________________

___________________________________________________________________

Present Address ____________________________________________________

___________________________________________________________________

Residing at current address since ______________________________________

Passport No.________________ Date of issue __________ Valid till __________

Passport issued by: Regional Passport Officer __________________________

Country for which Visa/Immigration has been applied _____________________

It is further stated that I am a citizen of India and have not been involved
in any criminal case in India and that there is no criminal case pending against
me in the Court of Law.

____________________
(Signature of Applicant)
_________________
(Date)