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https%//uppolice.gov.in - Citizen Services- Private Sec. Agency

NIYANTRAK PRADHIKARI/A.D.G. L&O UP. LUCKNOW ds uke ls ykblsal 'kqYd@lR;kiu 'kqYd dk Mh
Mh cusxk A
,d tuin dk ykblsl 'kqYd 5]000@&]nks ls ikWp tuin dk ykblsl 'kqYd 10]000@&
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iqfyl baLisDVj izkbosV lqj{kk vfHkdj.k&9454401509
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Affidavi
(U/S 7(2) of the Private Security Agency(Regulation) Act, 2005)
I---------------------------------S/O--------------------------------Age--------------------R/O Hereby solemnly declares
(1) That I am citizen of India.
(2) That I have not been convicted by any court of law in India or abroad for an offence in
connection with
promotion, formation or management of any company(any fraud or misfeasance committed by
me in relation to any
company.
(3) That I have not been convicted by any court of law in India or abroad for an offence
prescribed punishment for
which imprisonment of not less than two years.
(4) That I have no link whatsoever with any organization or association which is banned under
any law or account
of their activities which pose threat to the national security or public order.
(5) That there is no case or information registered against me in the Police or with other
competent authorities for
committing or abetting the activities which are prejudicial to national security or public order.
(6) That I have not been dismissed or removed from any government service on the grounds of
misconduct or
moral turpitude.
(7) That my company/Firm/association is registered in India and no proprietor or majority
share holder as partner
or director in this company/Firm/association is citizen of country other than India.
(8) That I will ensure the availability of training prescribed for the security guards and
supervisors.
(9) That I will abide by theconditions of the licens

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izk:i&1
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iqfyl Fkkus dk uke

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10-mi;qZDr irs ij fdl rkjh[k ls fuokl dj jgs gSa] fyf[k;s

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nkSjku izR;sd fuokl&LFkku ds fy, bl izk:i dh vfrfjDr QksVks izfr;kWa nsuh gksxhA izk:i
dh QksVks izfr nh tk ldrh gS] ijUrq izR;sd izk:i ij ewy QksVks rFkk gLrk{kj visf{kr
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Fkkus dk uke
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iqfyl v/kh{kd dh fjiksVZ
ftyk
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pykus ds fy, vuqKfIr izkIr djus ds fy, vkosnu djrk gS %&
1- vkosnd dk iwjk uke %------------------------------------------------------------------------------2- vkosnd dh jk"Vh;rk %-------------------------------------------------------------------------------3- iq=@iRuh@iq=h Jh----------------------------------------------------------------------------------------4- vkoklh; irk-------------------------------------------------------------------------------------------5- irk tgkW vkosnd viuk vfHkdj.k izkjEHk djus dk bPNqd gS-----------------------------------------------------------------------------------------------------------------------------------------------6- izkbZosV lqj{kk vfHkdj.k dk uke--------------------------------------------------------------------7- vfHkdj.k ds LoRo/kkjh] Hkkxhnj] cgqla[;d 'ks;j /kkjd] funs'kd rFkk v/;{k dk uke
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uke---------------------------------------vk;q---------------------------------------inuke-----------------------------------10- laj{kk lsokvksa ds fy, iz;ksx fd;s tkus okys miLdj
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2
11- onhZ ds C;ksSjs ftlds vUrxZr jax Hkh gS ;fn vkosnd ds futh lqj{kk xkMksZ i;Zos{kd ds
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izf'k{k.k lqfo/kk nsus okys dk uke o irk nhft, A
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FORM 1
(See rule 3)
Form for verification of Antecedents of Applicant
Thumb Impression of the Applicant...............................
Signature of the Applicant..............................................
Passport size recent
Photograph attested
by Class1 Gazetted
Officer

Form Number

For Offcial use only

Name of the police station sent for
police verification

Date

Fee Amount Rs...............................................D.D./B.C. .....................

Name of Bank.................................................D.D./B.C.No.................
Date of Issue....................
Please read the instruction carefully before filling the form. Please fill in BLOCK
LETTERS:(CAUTION: Please furnish correct information. Furnishing of incorrect
information or suppression of any factual information in the form will render the candidate
unsuitable for grant of licence)
1.

Name of applicant in block letters (Initials not allowed)

Last name...........................First name............................

2.
If you have ever changed your name, please indicate the previous
full ............................................................................
3.

Sex (Male/female)..................................................

4.

Date of birth............................................................

5.

Place of birth: Village/town........................................

name(s) in

6.
Father's full name/legal Guardian's full name (including surname, if any) (Initials
not allowed) ...........................................................
7.
Mother's full name in block letters (including surname, if any):(Initials not allowed)
.............................................................
8.
If married, full name of spouse in block letters (Including surname, if any): (Initials
not allowed)......Smt. Shuchi Sawhney .....................................

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-29.

Present Residential Address including Street No./Police Station, village and

District. (with PIN code)....---------------------------------------------------------------------------Telephone no./Mobile No............................................

10. Please give the date since residing at the above mentioned address :
DD MM YYYY...........................................................
11. Permanent Address including Street No./Police Station, village and District. (with
PIN code)...............................................................................................................
............................................................................................................
12. If you have not resided at the address given at COLUMN (9) continuously for the
first five year, please furnish the other address (addresses) with duration(s) resided. You
should furnish additional photocopies of this form for each additional place of stay during
the last five year. Forms may be photocopies, but photograph and signature in original are
required on each form.
From ...................to. ........................From. ....................to.................
............................................................................................................
13. In case of stay abroad particulars of all places where you have resided for more than
one year after attaining the age of twenty one
years..................................................................................................................................
..........................................................................................
14.Other details :
(a) Educational Qualifications
(b) Previous positions held if any along with name and address of employers :
(c) Reason for leaving last employment :
(d) Visible Distinguishing Mark:
15. Did you earlier operate any Private Security Agency or were in partner, shareholder
of Director? If, yes, then furnish the name, address of the Agency and particulars
:...............................................................
16. Are you a citizen of India by: Birth/Descent/Registration/
Naturalzation :
If you have ever possesed any other citizenship, please indicate
citzenship................................................................................................

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-317.Have your at any time been convicted by a court in India for any criminal of sentenced
to imprisonment ? If so, give name of the court, case number and offence (attach copy of
Jugment).
......................................................................................................
18. Are and criminal proceeding pending against you before a court in India ? If so, give
name of court, case number and offence.
..........................................................................................................................................
....................................................................
19. Self-Declaration :
The information given by me in this form and enclosures in true and I am solely responsible
for accuracy.

(signatur/T.I. of applicant)
Date...........................
Place...........................
20. Enclosures :
.............................................
...............................................
(signatur/T.I. of applicant)
(Left Hand Thumb Impression if Male and Right Hand Thumb Impression if Female)
For Office use only
File No...........................................
Date of issue of Character and Antecedents Report............................
(signature of Police station in charge)
Name of Police Station..............................
Name of District......................................
N.B. Cancel whatever is not applicable.

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1.

REPORT OF THE OFFICER INCHARGE OF THE POLICE STATION

(TO BE FILLED BY S.O./S.H.O.)
Whether the particulars furnished by the applicant are correct.Yes/No

2.
3.

Whether the identity of the aplplicant in photo is correct.

Yes/No
Whether the applicant residing at the address furnished ,
Yes/No
by him for the one year.
4.
Whether there is any case pending investigation/trial against Yes/No
the applicant .
Details of FIRs/cases pending investigation/grial are as under :S.No. First Information Sections of Law Police Station Whether pending
Report No.
investigation/trial

5.
Whether applicant have been convicted by any court.
S.N. FIR
Case
Name
Name
Section Date Of
NO.
No
of
of
Of Law Judgment
Police
Court
station

Yes/No
Whether
Discharged/
Acquitted/
convicted

6.

Yes/No

7.
8.
9.
10.

Whether the apolicant is engaged in any activity

which is anti-social or dangerous to the public safety/
Public order (if yes, give details)
Whether the general reputation of the applicant is good
whether the applicant has been removed/dismissed
from any governmet sercive (if yes, give details)
Whether the applicant has any links with any banned
organization.
Whether giving license to the applicant will pose a threatto
the national security/integrity/ stability of the nation and
issuing a license will not be in the interest.

Yes/No
Yes/No
Yes/No
Yes/No

(Signature of the Officer-in-charge of Police Station)

Name of Police Station
Office Seal.
Date :....................
No.........................

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Date.

REPORT OF THE SUPERINTENDENT OF POLICE

District........................
The character and antecedents of
Shri.................................S/O............................. have been verified.
The applicant has earlier operated/ not operated Private Security Agency
individually/ in partnership of other. The details are as under :1.
The applicant possess/ does not posses any special
qualification,
skill
which may facilitate his operation of
Private Security Agency. The details are
as under :2.
This office has no objection if the applicant Shri.....................................
S/O...................................................is granted license under section V11 of the
Private Security Agency Regulation Act. 2005.
OR
3.
This office does not fnd the applicant suitable of grant of license for Prviate
Security Agency.

Signature of the District Superintendent of Police

District.........................
Date.............................
Seal..............................

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Form-V
(See rule 8)

APPLICATION FOR NEW LICENCE/RENEWAL OF LICENCE TO

ENGAGE IN THE BUSINESS OF PRIVATE SECURITY AGENCY
To,
The Controlling Authority/
A.D.G. Police L &O UP
Lucknow.
The undersigned hereby applied for obtaining a license to run the business of
poerating services in the area of Private Security Agencies.
1.

Full name of the applicant.------------------------------------------

2.

Nationality of the applicant.--------------------------------------

3.

Son/Wife/daughter of :---------------------------------------------

4.

Residential Address :---------------------------------------------------------------------------------------------------------------------------------------------

5.

Address, where the applicant desires to start his Agency.

------------------------------------------------------------------------------

6.

Name of the Private Security Agency.---------------------

7.
Name and addresses of Proprietor, partner, Majority shareholder,
Director and Chairman of the Agency.---------------------------------------------- ------------------------------------------------------------------------------------------8.

Name and extent of facilities available.-------------------------------

9.

Qualification of staff engaged for imparting instruction ;

Name..........................................................
Age...........................................................
Designation..............................................

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-210.
(a)
(b)
(c)
(d)

Equipments which will be used for Security Services.

Door Framed Metal Detactor (DFMD)
Hand Held Metal Detector (HHMD)
Mine Detectors
Other Detectors
(i)
Wireless Telephones
(ii) Alarm Devices
(iii) Armoured Vehicles
(iv) Arms.

11. The particulars of the uniform including color in case the

applicant intends to use any uniform for the Private Security
Guards and Supervisors of the Agency.Shoes------------, Shocks----------, Paint -----------,Shirt------------,Laneyard---------------,Badge-------------,Cap--------, Logo------------------------------------------------------------------------------12. Does the applicant intend to operate in more than one
districts ? If so the name of the Districts :
13.1.......................2....................................3........................................
4......................................... 5...................................
14.

Does the applicant intend to operate in the intire state ?

15. Does the applicant possesses the training facility in its own or will get
on outsourcing basis ? The name and address of training facility should be furnished.

Signature
Name of the applicant.
Address of the applicant
Telephone No- of the applicant.
Date of application.
Enclosure :
1.

Copy of current Income Tax Clearance Certificate.

Affidavit as prescribed in Section 7 of sub-section (2) of the Act

2.
Other enclosures.

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3.

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