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POLICE VERIFICATION REPORT

Note for the Police:


(a) (b) Please ensure that all columns are answered Use additional sheets for details if required

File No.: Applicant's Name: Father's/ Spouse's Name: Address:

Certified that I met/was visited by police authorities in order to carry out my/my dependent minor childs verification on date: ____ ______ ___ at time: _________ ____
Note for Applicant: The Police Verification Process is deemed to be completed only after receipt of the Police Verification Report at the Passport Office. Signature/Left thumb impression of applicant (or authorized signatory in case of minors/other applicants who cannot sign)

1. Is the photograph given in the PP Form same as that of the applicant? 2. Are the applicants name and personal particulars same as that mentioned in the PP Form? 3. Has the applicant been living (except for visits outside) at the address and duration of stay as mentioned in the PP form, subject to stay of maximum one year? 4. Are you satisfied that the applicant is a citizen of India?
For Questions 1 to 4 above, if any of the answer is NO, provide required details in the box given below:

Part A

Yes Yes Yes Yes

No No No No

5. Has the applicant, during the past five years been convicted and sentenced to imprisonment of two years or more? 6. Is there any "Court Order" from any Court against the applicants departure overseas? 7. Are any Proceedings against the applicant pending in any Criminal Court? 8. Are there any pending Warrants of Arrest or Warrants/Summons for Appearance against the applicant? 9. Has the applicant travelled abroad?
For Questions 5 to 9 above, if any of the answer is YES, provide required details in the box given below. If answer to Question 5, 6, 7 and/or 8 is YES, specify the case number and relevant details of the case.

Yes Yes Yes Yes Yes

No No No No No

10. Is the applicant an employee of the Central or State Government/ the Armed Forces/Statutory Body /Public Sector Undertaking? If Yes, please specify the name of organization: _____________________________________ 11. Do you have any information regarding the applicant holding any passport?

Yes Yes

No No

If Yes, please provide the Passport No.: __________________, Date of Issue: _________________, Place of issue: ________________________________________________________________. ID and Name of Investigating Officers Date of Investigation Signature

12. Has the applicant indulged, or likely to indulge in any activity which could be prejudicial to the sovereignty and integrity of India, the security of India, friendly relations of India with any foreign country, or the interests of the general public? If Yes, attach additional sheet with required details. BASED ON THE ABOVE, ISSUE OF PASSPORT TO THE APPLICANT IS: Recommended (Clear PVR) Not Recommended (Adverse PVR)

Part B

Yes

No

Date:_______________________

For Sr. Superintendent of Police Name of the Officer with Seal

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