FROM To THE SUB INSPECTOR OF POLICE Sir, Sub; ISSUANCE OF POLICE CLEARATICE CERTIFICATE. a on I request you to issue me a Police Clearance Certificate for submitting at M/s. BPCL — Kochi Refinery, Ambalamugal for satisfying the eligibility creteria tg work as a contract labour under Contractors, Thanking you, Yours faithfully, Place: Date:APPLICATION FORM FOR ISSUE OF POLICE CLEARANCE CERTIFICATE 1. Name in full (Capital) 2. Name of Father/Mother 3. Age 4. Sex (Male/Female) 5. Present address in full: House Name /No Village Panchayath Police Station Dist State Pin Code No : Phone No. : 6, Permanent Address in full House Name / No Village : Panchayath : Police Station Dist State PinCode No phone No. 7. Married/Unmarried 8 If married, Name of Wife/Husband : 9. Address of Wife/Husband House Name / No Village Panchayath Police Station Dist State Pin Code No 10. Identification Marks1, Name and addresses of two responsible persons of your locality or two reference to whom you are known 72, Is any case pending against you in any Court of Law at the time filling this Form? If so, give ease No and other details. a. b 1 certify that the foregoing information is correct and complete to the best of my knowledge and belief, Space for Enquiry Date; Signature of the Applicant Name Date Place report (For Use of Police Officer only)POLICE CLEARANCE CERTIFICATE SI. No. PCC No. “ dated ‘Sub : Pre - Verification of Character and Antecedents of Contractors / Contract Workers [As per the records available in this Station there is nothing adverse against the individual Name of the individual se ‘Sub Inspector of Police (Details on the reverse) PARTI F THI AL Name Father's Name Age .. Identification mark House | House No Post Office Panchayath .. Taluk z Dist. . Pin code a: Tele. No. Signature of the splice Individual ‘Sub Inspector of