මෙෙ අයදුම්පත්‍රය මම ිලම ිකුත් මරම /இவ்யிண்ணப்஧஧டியம் இ஬யசநாக யமங்கப்஧டும்/ THIS APPLICATION IS ISSUED FREE OF CHARGE

පයොමු අංකය : ...........................

Official use only:
Date - கு஫ிப்பு இ஬ : .................................
Checked by - Reference No: ...........................

පපොලිස් පෙපාර්තපේන්තුව
ப஧ா஬ிஸ் திணணக்க஭ம்
Police Department

ப஧ா஬ிஸ் இணசவு சான்஫ிதழுக்கா஦ யிண்ணப்஧ப் ஧டியம்

ப஧ா஬ிஸ் தண஬ணநனகம் பகாழும்பு 01. இ஬ங்ணக
POLICE CLEARANCE CERTIFICATE REQUEST APPLICATION
POLICE HEADQUARTERS, COLOMBO 01, SRI LANKA

o;a; iy f;dr;=re bx.%Sis NdIdfjka muKla mß.Kl .; flf¾’ tu ksid whÿñm; bx.%Sis niska iñmq¾K l< hq ;=h’ jeä úia;r ioyd 05” 06 iy 07 hk msgq j,
we;s Wmfoia lshjkak’ ^isxy, $ bx.%Sis $ fou,&

தபவுகள் நற்றும் தகயல்கள் ஆங்கி஬ பநாமினில் நட்டுமந ஧திவு பசய்னப்஧டும். ஆணகனால் யிண்ணப்஧ப் ஧டியம் ஆங்கி஬
பநாமினில் நாத்திபம் ஥ிபப்஧மயண்டும். மந஬திக யி஭க்கத்திற்கு 05,06,07 ஆம் ஧க்கத்தில் உள்஭ அ஫ிவுறுத்தல்கண஭
தனவுபசய்து யாசிக்கவும்.(rpq;fsk;/jkpo ;/Mq;fpyk;)

Application must be filled in English as all information will be computerized. Please read instructions at Page – 05, 06 and 07
for clarification. (Sinhala/Tamil/English) before filling the application.

NOTE - PLEASE FILL ALL IN CAPITALS / whÿñm; bx.%Sis f,dl= wl=rska (CAPITALS) iñmq¾K l< hq;=h’

01. Nationality:

02. If not Sri Lankan, were you a Sri Lankan before: Yes No
DD MM YYYY
03. The date, Citizenship obtained from other country:
DD MM YYYY
04. Date of Birth: 05. Age: (Years)

06. i. NIC No:

ii. New NIC No:

07. Passport No:

08. Country:

09. Reference of the High Commission/Embassy/Consulate:

10. High Commission/Embassy/Consulate Name (Addressee & the Name of the authority):

11. Applicant's Name in full as appear in the NIC :

12. Applicant's Name in full as appear in the Passport:

13. Which name the certificate should be issued :

As appear in NIC: As appear in the Passport:

14. Issued Date of Passport: DD MM YYYY

15. Gender: Male Female

16. Status: Rev. Married Unmarried Divorced Widow

17. Occupation:

18. Purpose : Residence Visa Temporary Visa Employment

Student Scholarship Visit

19. Present address in Sri Lanka:

Line 1
Line 2
City
State/Province
Postal/Zip Code

20. Overseas Address:

21. Whether Police Clearance applied earlier? Yes No

22. Whether Certificate issued? Yes No

If yes, the Country:

Reference No.:
DD MM YYYY
Date of Issue:

23. Give Address to residences during the period of Certificate required:

(If space is insufficient, please attach a special annexes)
Date (DD/MM/YYYY)
Address Police Area From To
24. Application submitted by :
1. Applicant:
2. Authorised person : Yes No

ii. Relationship: Father Mother Wife Husband Daughter

Brother Sister Son

iii. Relation’s Name:

iv. Relation’s NIC/Passport No:

25. Address the police clearance certificate need to be sent:

Line 1
Line 2
City
State/Province
Postal/Zip Code
Country

26. Mobile No: + 9 4

27. Email:

28. Spouse Full Name:

29. Nationality:

30. Passport No:

31. NIC No:

32. Payment Amount Rs.:

33. Mode of Payment:

Cash
BR No.:
Date of Issue: DD MM YYYY

Credit / Debit Card

Card Holder Name:
Card No.:
DD MM YYYY
Expiry Date:
Issued Bank:

Easy Cash
Details: ………………………………………………………………………………………
 Cheque
Cheque No:
Account No:
Account Holder Name:

Wire Transfer:

Details: ....……………………………………………………………………………………

34. Are you an Applicant referred from the

Sri Lanka Foreign Employment Bureau (SLBFF): Yes No

…………………………. ……………………………………….
Date Signature of Applicant

(For office Use Only)

Police Station/Office Date Sent Date Received Remarks

35. Mode of Dispatch: Posted Handed over to the Ministry of foreign affairs

DD MM YYYY
36. Date Dispatched:

37. Authorized Officer:

……………………………………………..
Signature of OIC