FORMAT OF APPLICATION FOR POLICE CLEARANCE CERTIFICATE Recent

Photograph
1. Name of the Applicant (in Block letters) :
of the
2. Name of the Father :
Applicant to
3. Name of the Spouse : be pasted

4. Date of Birth :
(copy of Birth Certificate, Admit Card Or document
Of School leaving examination to be attached)
5. Full Address
a) Present (where the applicant has been :
residing continuously for the last one year)

b) Current (where the applicant has been :

residing for less than one year)

c) Permanent :
[Police Station to be mentioned in (a), (b) & (c)]

6. (a) Nationality & PASSPORT No. :

(b) Date of Issue :
(c) Date of Expiry :
(d) Place of Issue :
7. Purpose and Period for which Police Clearance :
Certificate is required

8. Purpose for which VISA is required :

9. Name, Address & Signature of TWO responsible:

Citizens of the locality knowing the applicant

I solemnly declare that all the above particulars are true and I do not have any criminal
records and there is no case pending against me in the last 6 months or before.

Signature of the Applicant with date

Note: - One extra copy of the Photograph and a Photocopy of his/her Passport should be enclosed by the applicant
along with his/her application.