PST PCC No. DATE APPLICATION FOR POLICE CLERANCE CERTIFICATE BY AN INDIAN PASSPORT HOLDER ‘SURNAME NAME ‘Name of the applicant with aliases irany (CIN BLOCK LETTER) Father / Husband's Name Present Address (to be verified where stayed for more than one year ) “Telephone No. Local Police Station Penod of staying in Munibai ace Particulars of the places (with period oF residence) where you have resided dusing proceeding years since birth D Taformation of NAME OCCUPATION PRESENT ADDRESS T_| FATHER _| MOTHER I [HUSBAND WIFE Iv | BROTHER ‘V_[SISTER ‘a)_| Date of Birth 'b) | Place of Birth ‘Educational Qualification showing places of education with years in School Collages. ‘Present Occupation/Service with all particulars ‘Reasons for obtaining Police Clearance Certificate for which Country 10 Particulars of Passport Passport Ne. Date of Josue. Place of Issue Valid DateTT | Have you ever been arrested Prosecuted / Convicted / Detained ? If so, give particulars T2 [Have you ever taken active part in Politics ? If so, give particulars TS | Identification Maske Tt | Name and addresses of two responsible | 1) persons ef your locality to whom you are known I certify that the forgoing information is comect and complete to the best of my knowledge and belief, Place Date (Signature of the Applicant ) Note: Application should submit the photocopies of the following documents duly attested by Gazzeted Officer or First Class Magistrate 1. Attested Xerox copy of Valid Passport & 2 passport size photographs 2. Attested Xerox copy of Residential Proof ( In addition to passport) i.e. Ration Card/ Societies Letter’ Electricity Bill / Telephone Bill, etc 3. Letter/instructions of the Embassy demanding the Police Clearance Cettificate A Demand Draft of Rs. 100/~ in favour of "THE COMMISSIONER OF POLICE, BRIHAN MUMBAI" as a charges for verification to be paid to the Govemment FOR OFFICE USE ONLY Verifiedby PST Police Clearance Certificate No. a Date of Issue Seal of the Issuing Authority