Form #461

‫بسمه تعالی‬
‫دفتر حفاظت منافع جمهوری اسالمی ایران – واشنگتن دیسی‬
EMBASSY OF PAKISTAN
INTERESTS SECTION OF THE ISLAMIC REPUBLIC OF IRAN
1250 23RD STREET N.W. SUITE # 200 WASHINGTON, DC 20037 TEL: (202) 965-4990 FAX: (202) 965-1073
WWW.DAFTAR.ORG E-MAIL: INFO@DAFTAR.ORG

Request for police clearance certificate

Please forward the following documents in order to receive a police clearance

certificate:

1- Original valid passport

2- Completion of attached Form #461
3- 8 passport photos based on the photo requirement sheet
4- 2 fingerprint forms (please do not fold)
5- Money order payable to the Embassy of Pakistan in the amount of $82 for
inside the U.S., and $102 for outside the U.S. (American Dollar)

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 Form #461
‫بسمه تعالی‬
‫دفتر حفاظت منافع جمهوری اسالمی ایران – واشنگتن دیسی‬
EMBASSY OF PAKISTAN
INTERESTS SECTION OF THE ISLAMIC REPUBLIC OF IRAN
1250 23RD STREET N.W. SUITE # 200 WASHINGTON, DC 20037 TEL: (202) 965-4990 FAX: (202) 965-1073
WWW.DAFTAR.ORG E-MAIL: INFO@DAFTAR.ORG
APPLICATION FOR POLICE CLEARANCE
‫پرسشنامه متقاضیان عدم سوء پیشینه اتباع خارجی‬
‫محل الصاق عکس‬
 Please answer ONLY the English parts of the questionnaire.
 Failure to answer questions may result in rejection of your application. ‫توسط نمایندگی‬
 Type or print clearly.

1- First Name: :‫ نام‬-1

2- Last Name: :‫ نام خانوادگی‬-2
3- Middle Name: :‫ نام مستعار‬-3
4- Father's Name: :‫ نام پدر‬-4
5- Date and Place of Birth: :‫تاریخ و محل تولد‬-5
6- Sex: ( )Male ( ) Female ‫ ( ) مرد ( ) زن‬:‫جنس‬-6
7- Marital Status : ( ) Single ( ) Married ‫ ( ) مجرد ( ) متأهل‬: ‫ وضعیت تأهل‬-7
8- Nationality: : ‫ ملیت‬-5
9- Passport Number: :‫ شماره گذرنامه‬-9
10- Date an d Place of Issue of passport :‫ تاریخ و محل صدور گذرنامه‬:11
11- Date of Last Entry in to Iran: : ‫ تاریخ آخرین ورود به ایران‬-11
12- Purpose of your last trip to Iran: :‫ علت اقامت در ایران‬-12

13- Length of stay on your last trip to Iran : :‫ مدت اقامت در ایران‬-13
14- Occupation and Employment address in Iran : :‫ شغل و آدرس محل کار در ایران‬-14

15- Residential address in Iran: :‫ آدرس محل سکونت در ایران‬-15

16- Date of last departure from Iran: : ‫ تاریخ آخرین خروج از ایران‬-16
17- Port or airport of the last departure from Iran : ‫مرز آخرین خروج از ایران‬-17
Address and Phone Number In U.S.:
Street:
City: State: Zip Code:
Home Phone: ( ) _ _ _ - _ _ _ _ Cell Phone: ( ) _ _ _ - _ _ _ _ Work Phone: ( )___-____
Email:
Declare that the e above information Is true and correct. .‫مشخصات گذرنامه مندرج در فرم تأیید میگردد‬
Applicants Signature: ----------------

Date Signed:

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