To be filled by the Indian Passport holder only

PERSONAL PARTICULARS FORM

1. Full name of the applicant with alias (if any) : ________________________________________________

2. Previous name (if any) : ________________________________________________
3. S/o, D/o, W/o : ________________________________________________
4. Date of Birth : ________________________________________________
5. Place of Birth : ________________________________________________
6. Permanent Address : ________________________________________________
7. Present Address : ________________________________________________
8. Previous Address : ________________________________________________
9. Any Criminal case or criminal proceeding :
pending in any court of Law in India ________________________________________________
10. Telephone No. : ________________________________________________
11. Residing since : ________________________________________________
12. Whether Owner or Tenant : ________________________________________________
13. Occupation : ________________________________________________
14. Whether Indian Passport Holder : Yes/No, if Yes, details of passport

Passport No. ___________________________

Issue Date ____________________________

Valid up to ____________________________

Place of issue __________________________

15. Husband name (if married) : ________________________________________________

16. Have you visited abroad earlier : ________________________________________________
17. Present purpose of visit : ________________________________________________
18. Name & Address of two responsible persons of your locality who will vouch for you

1.)____________________________________________________________________________

2.)____________________________________________________________________________

19. Name of Country to be visited : ________________________________________________

Place: _______________________

Date: ________________________ (Signature of Applicant)

To,

The Senior Superintendent of Police,

Union Territory, Chandigarh.

Subject:- Issuance of Police Clearance Certificate.

Sir,

With due respect, it is submitted that I/We intend to visit _____________________

I am in urgent need of Police Clearance Certificate, Therefore, it is requested to kindly issue me the

same at the earliest, Photo copy of my passport is attached herewith. I shall be very thankful to

you.

Yours faithfully,

Name ______________________

Father Name __________________

R/o__________________________

_____________________________

Dated:___________ _____________________________