seecutegs ented fae eneifieemamULisgead BevOUROTe aipiRiLlQ eR APFLCATION = IBEORD FREE OF CHARGE ci genet ain gs + Reference No ued gimemésend Paice garment 208d Bdaron cafins ccm D9 ast8 69 26d aageae amet 0) / @ ae Qunedien Qensey onc Haypdonen arian uqenis Quuediein sencvemnwenia anggidy +1. Greotixenss POLICE CLEARANCE CERTIFICATE REQUEST APPLICATION POLICE HEADQUARTERS, COLOMBO 01, SRILANKA coo on eons anf memes wom contin nab. 80 dn gon anB abs Scheme cnt OD Dad mem OL Of we OF 600 SF coeee Sevan! toe TT ee) role wppL gaaKoecr stile QoNPUNG UWEEW YBa CeUULUG ajmeLiNe eraRULE URAL aptieer Gump Long GULCH Comps mABKHNG viene ad UREBEO aeter oIPaDIESAOSMmar SunIOeWg, cunAA ch panme/by atm) ‘Applicaton must be led in Pagich ar wl nfrmatin wil be conmputerned, Peace seed smctructions at Page ~0S, 06 and 07 ‘Sreiangcaton, (Sinhala Tamnl/Paghsh) befre ling the npplcatien [NOTE- PLEASE FLL ALLIN CAPITALS /qaqtom $8 eCim ARK (CAPITAL cab oe OR. 01. Nationality: 02, tf sot SriLankan, were youa SriLankan before: Yes [] No (03. The date Citizenship obtained fiom other country SPB conte FEBPEBRT) © ie 0 06, i, NIC No: ii New WIC No ] 07, Pesspoxt No 08. County. 09, Reference of the High Commission/EnbessyiConsulate: 10, High Commission EmbassyiConsulate Name (Addressee & the Name of the authority): 11. Applicant's Name in full 12, Applicant's Name in full13, Which name the cenificate should be issued. AsappeinNIC:[—] AsappeerinthePaspast [| M4 teuedDa of Pepa PO gpa re 15. Gender Male [] Female 16. Status: Rev. im Married [ ‘Unmarried Divorced. ‘Widow 17. Ocempetion = [TT | TT] [TET TTEr ry 18. Purpose Residence Visa [] TemporaryVisn [_] Employment [—] Student [] Scholarship |] visit 19, Present addvess in Sri Lanke: Line 1 Line 2 City State/Province Postal/Zip Code 20, Overseas Addvess 21, Whether Police Clearance applied ens? Yes wo 22, Whether Cestiicate issued? Yes No yes, the Country Reference No Date of Issue: 23, Give Adévess to residences dusing the period of Certificate required: (Of space is insufficient, please attach a special aunexes) ‘Date (DD/MMATYY) Address Police Area From To24, Application submitted by 1 Applicant Authorised person ii, Relationship’ Father ii, Relation’s Name: iv. Relation’s NIC Passport No: Brother Yes Mother Wife Husband Daughter Sister Son 25, Addvess the police clearance certificate need to be sent: 30 31 32 33 Line Line City State/Province Postal/Zip Code Country ‘Mobile No: Fo Email: ‘Spouse Full Name: Netionality Pessport NIC No: Peyment Amount Rs 1 2 No: ‘Mode of Payment: Cash BRNo. Date of Issue Credit /Debit Card Card Holder Name CardNo. Expiry Date Issued Berk EesyCash Details: