Gurgaon Police

Information on Domestic Help/Tenant

1. Sector/Village :-
Colony/Society :-
2. Plot no./Flat no. /House no.
3. Name & Father’s Name of Employer/Landlord with Mobile no.

4. Particulars of Employee/Tenant
Full Name :- Phone no.
alias
Father Name :-
Spouse Name :- Occupation :-
Nationality :- Religion :-
Sex :- Age :- Caste :-

5. Permanent Address
House No.
Sector/Village/Locality :-
Police Station :-
District & State :-
Landline/ Mobile no.
Proof of Identity (Voter card/Driving License/Ration Card etc.)
Two References 1.
2.

6. Local (Current) Address

House no. Residing at current address since
Sector/Village/Locality
Name of Landlord & Address Police Station :-
Police Post :-
Mobile no.

7. Nature of Employment Place of Work

(Domestic Servant/Shop Employee/Industrial
Worker/Chowkidar/Dhobi/Tradesman/Craftsman etc.)
8. Particulars of Previous Employment (in case of Employee)
Nature of Employment :-
Address :-
Particulars of Previous Employer (with mobile no.)
9. Local Reference (Name, Phone no. & Address)
1.
2.

10. Reference from Native Place (Name, Phone no. & Address)
1.
2.

11. Particulars of Family members residing with the Tenant/Employee

Sr. No. Name Age Sex Relation Occupation Mobile no.

This is only Information Form. I am getting his/her Police

verification done separately by addressing the concerned jurisdiction SP (of permanent
address) in prescribed Performa, taken f rom websit e of Haryana Police.

Signed by

Employers/Landlord.