Embassy of India Stockholm

Application Form for Police Clearance Certificate

(Please Use Typewriting or Black Ink Pen with Clear Handwriting and Block
Letters)
Write names in extended forms and not initials

Name of Applicant : VARUN PRATAP

Previous or Maiden Name :

_____________________________________________

Father/Husband’s Name : HARI KRISHNA PRASAD

Date of Birth : 04/06/1985 Place of Birth : BALRAMPUR

Present Nationality : INDIAN

Date of acquisition of foreign nationality, if applicable :

________________________

Passport No. : S1233821 Place of Issue : STOCKHOLM

Date of Issue : 25/10/2017 Passport Validity : 21/10/2027

Permanent Address : 327, KANDBHARI, BALRAMPUR, UTTAR

PRADESH, 271607, INDIA

Present Address : C/O ARMAND BROJERDI, VIREBERGSVÄGEN 14,

LGH 1402, 16930 SOLNA

Contact Particulars :

Office/Home : 0764155590 Mobile : 0764155590

Fax : ______________________ E-mail: PRATAP.VARUN85@GMAIL.COM

Purpose for which PCC is required : TO PROCESS VISA FOR LITHUANIA

Declaration :

I VARUN PRATAP, presently INDIAN national and holder of Passport No.

S1233821 dated 28/05/2018 hereby declare that there is no criminal
or civil case pending against me in any Court of India.
28/05/2018 STOCKHOLM ……………………………….
(Date & Place) (Signature)