Form for Security Passes for Graduate/Guest 1” x 1”

Part A

1) Name 2) Father’s Name

3) NIC No 4) Caste
5) Religion 6) Sect
7) Address
a. Present
b. Permanent
8) Date of Birth 9) Profession
10) Telephone No. Off Res Mob
11) Education
12) Criminal Record, if any
13) Nature of Duty/ Assignment during the Event
14) Three References
S.# Name Father’s Name Address Profession Relation Telephone
1
2
3

15) Affiliation with any proscribed organization (if any)

16) Whether borne on 4th Schedule of ATA?
17) I hereby solemnly declare that the above stated information is correct to the best of my knowledge.

Name Signature

Part B
18) Nomination Department/ Organization
Certified that Information provided by him/ her is correct to the best of my knowledge. Moreover, the person is
emotionally stable and nothing adverse against his/ her conduct has come to notice, which may be hazardous from
security point of view.

Name Signature