Form

(see rule
Form
Thumb

for

Impression

Signature

verification

of

I
3)

Antecedents

of

Applicant

of the Applicant

passport size
recent
~otograph
attested by
Group A
Gazetted Officer

of the Applicant

For official
Formnmnber

N~

of the

police

use only

station

sent for

police

Date

verification

I
Name
Date
Please
Fee ~unt
ofofread
Issue
BankRs.
the

LETTERS:

instnlcDons
D.D
/D.D.No ny

(CAUTION:

informaDon

or

c:andidate

unsuitable

1. N~

Please

suppression

of applicant

Last ~

for

(Initials

grant

furnish
any

name(s)

tilling

correct

factual

the

fonn.

informaDon.

informaDon

Please

the

form

not allowed)
.

your

naIIE,

please indicate

the

in full

3. Sex (male / female).

r .--" ,

District
5.
4.Date
PlaceofofBirth:
Birth: Village / Town
State &C\)untry I'

fill

Furnishing
in

of license)

First ~

2. If you have ever changed

previous

of

before

~- "

in

of
will

BLOCK

int.orrect

render

the

6.

Father's

Full

surname.

7.

if

Mother's

If

9.

Full

not

Present

Name

(including

allowed)

(including

Name

surname.

if

any):

of

Spouse

(including

surname.

if

any).

allowed)

Residential

Address.

village

Telephone
10.
Please

not

Full

allowed)

married.

station,

Guardian's

(Initials

Name

not

.(Initials

Legal

any):

Full

(Initials

8.

Name/

and

No./Mobile
give

including

District

the

date No

(with

since

Street

PIN

No./Police

code)

residing

at

the

~~~~
above-mentioned

address:

DD

MM

yyyy

11.

Pennanent

Address

District

12.

last

If

(with

YOu

have

five

not

ear

You

should

furnish

during

the

From

in

original

Street

No./police

address

given

station.

village

and

code)

resided

lease

stay

signature

including

PIN

at

furnish

the

additional

last

five

are

the

other

address

QhotocoDies

year

reQuired

To

.F

COLUMN

each

mav

(9)

addresses

ofthis

onns

on

at

be

fonn

QhotocoDied.

continuouslv

with

for

duration

each

I2hotof!Iaph

fonn.

~~

From

additional

but

To

fo

resided.

I2lac

and

...13. In case of stay abroad particulars of all places whe~e 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 operated any Private Security Agency or were its partner, majority
shareholder or Director? If yes then furnish the name, address of the Agency and its
license particulars.

16. Are you a citizen of India by: Birth/ Descent/Registration/Naturalisation: If you

have ever possessedany other citizenship, please indicate previous citizenship
.

17. Have you at any time been convicted by a court in India for any criminal offence
and sentenced to imprisonment? If so, give name of the court, case number and
offence. (Attach copy of judgment)

'3

18. Are any criminal proceedings pending against you before a court in India? If so,
give name of co~
case number and offence
"

"" "

"

" ,. """
"." "." "

"" ; ...""." "".""

"

"...

19. Self-Declaration:
The

infonnation

responsible

given

by me

in this

fonn

and enclosures

is true

and I am solely

for accuracy.
(SignatureIT

.1* of applicant)

Date
Place

".

20. Enclosures:

"

(.Left

"."

"

Hand Thumblmpression

FOR OFFICE

"

"

ifMale

"

(Signature
""

I T .1*. of applicant)

and Right Hand Thumb ImpTession ifFemale)

USE ONLY

Date
File No::
of issue of C&A Report. : .

(Signature ofPolice

station In charge)

Name ofPolice

Station

Name ofPolice

district
.

*N.B. Cancel whatever is not applicable.

14