APPLICATION FORM FOR PCC https://portal6.passportindia.gov.

in/Online/secure/loginAction

CONSULATE GENERAL OF INDIA

LEVEL 6, 12 ST. GEORGES TERRACE, PERTH, WA-6000, AUSTRALIA
00-61-8-92214205, https://cgiperth.gov.in/

APPLICATION FORM FOR POLICE CLEARANCE CERTIFICATE

Generated On: 12/3/2020, 2:20:04 PM

SERVICE REQUIRED
Application Reference Number 20-2002902706

IMMIGRATION PURPOSES OTHER THAN

Purpose of PCC
CITIZENSHIP

Country for which PCC is required AUSTRALIA

PASSPORT DETAILS
Passport Number P2933866

Date of Issue (DD/MM/YYYY) 29/05/2017

Date of Expiry (DD/MM/YYYY) 28/05/2027

Place of Issue KUALA LUMPUR

File Number MYSP00553017

APPLICANT DETAILS
Applicant's Name KALIYA PERUMAL PALANISAMY
Date of Birth (DD/MM/YYYY) 20/04/1987
Place of Birth (Village/Town/City) T PUDUPALAYAM
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN
Voter Id
Educational Qualification GRADUATE AND ABOVE
Employment Type PRIVATE
Organisation name
Aadhaar Number 387444102338

Note: Please paste your unsigned recent color photograph Size 2"X2" and Signature/Left Hand Thumb Impression in the box provided above.

FAMILY DETAILS
Father's Name PALANISAMY
Mother's Name THAIYALNAYAGI
Legal Guardian's Name
Spouse's Name NANDHINI
PERMANENT ADDRESS IN INDIA
2 135 MARIAMMAN KOIL STREET, T PUDUPALAYAM,
Address PERIYATHACHUR
VILUPPURAM, TAMIL NADU
PIN 605652
Mobile/Tel No. 6369757491

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E-mail KALIYAP2004@GMAIL.COM
PRESENT ADDRESS IN COUNTRY OF DOMICILE
366, BANROCK DRIVE, ELLENBROOK
Address
WESTERN AUSTRALIA, AUSTRALIA
Mobile/Tel No. 0484186022
OTHER DETAILS
Have you ever been charged with criminal proceedings or is any
NO
arrest warrant/summon pending before a court in India?
1) Provide the following details if there are any criminal proceedings
pending against the applicant.
1.1) Are any proceedings in respect of an offence alleged to have
N
been committed by you pending before a criminal court in India?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.2) Has any warrant or summons for your appearance been issued
N
and pending before a court under any law for the time being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.3) Has a warrant for your arrest been issued by a court under any
N
law for the time being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.4) Has an order prohibiting your departure from India been made by
N
any court?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
2) Provide the following details if the applicant has been convicted by
a court in India.
2.1) Have you at any time during the period of five years immediately
preceding the date of this application been convicted by a court in
N
India for any criminal offence involving moral turpitude and sentenced
in respect thereof imprisonment for not less than 2 years?
Court Name and Place
Case/FIR/Warrant Number
Date of Conviction
SELF DECLARATION
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any other
country. I have not lost, surrendered or been deprived of the citizenship of India. I have not contravened any of the conditions relating to the
possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing any material
information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my application for an Indian
passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. I am liable to be penalized or
prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false information or to
suppress any material information with a view to obtaining passport or travel document.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me in the form is
bonafide.

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Place PERTH
Signature/Left Hand Thumb Impression of Applicant
Date 03/12/2020

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