POLICE VERIFICATION CERTIFICATE FOR INDIA

(SEPARATE FORM & PHOTO FOR DIFFERENT ADDRESSES)

(PLEASE MENTION THE NEAREST POLICE STATION NAME ALSO)

Name :

If the applicant has ever

changed name, previous name : Paste your
recent
Sex : Male/Female photograph
here
Father’s Name :

Mother’s Name :

Spouse Name(If married) :

Date of Birth :

Place of Birth :

Passport No. :

Date of Issue :

Place of Issue :

Permanent address in India along with nearest Police Station:

______________________________________________________________________________

______________________________________________________________________________

Period of stay__________________________________Telephone No._____________________

Any other address in India along with nearest Police Station where the applicant lived during the
last 20 years
1. _________________________________________________________________________

______________________________________________________________________________

Period of stay_________________________________Telephone No.______________________

2. _________________________________________________________________________

______________________________________________________________________________

Period of stay ____________________________Telephone No.__________________________

Signature of Applicant :
Date :
Place : Vienna