EMBASSY OF INDIA

VILLA NO 86 AND 90, STREET NO.941, AL EITHRA STREET, ZONE-63, ONAIZA, P.O. BOX
2788, DOHA, QATAR
00-974-44255777, http://www.indianembassyqatar.gov.in/

APPLICATION FORM FOR POLICE CLEARANCE CERTIFICATE

Generated On: 27/08/2019, 06:30:13

SERVICE REQUIRED

Application Reference Number 19-2001353466

Purpose of PCC UPDA MMUP EXAM Paste your

unsigned
Country for which PCC is required QATAR
recent color
PASSPORT DETAILS
photograph
Passport Number K5054848 Size 2"X2"
Date of Issue (DD/MM/YYYY) 28/08/2012

Date of Expiry (DD/MM/YYYY) 27/08/2022

Place of Issue CHENNAI

File Number MA01O1007321012

APPLICANT DETAILS
VENKATA SURYA KRISHNAM RAJU SRI
Applicant's Name
KAKARLAPUDI
Date of Birth (DD/MM/YYYY) 25/01/1992
Place of Birth (Village/Town/City) MUMMIDIVARAM
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN
Voter Id
Educational Qualification GRADUATE AND ABOVE
Employment Type OTHERS
Organisation name
Aadhaar Number

Note: Please paste your unsigned recent color photograph Size 2"X2" and Signature/Left Hand Thumb Impression in the box provided above.

FAMILY DETAILS
Father's Name VENKATA SATYA GOPALA RAJU SRI KAKARLAPUDI
Mother's Name
Legal Guardian's Name
Spouse's Name MONISHA DATLA
PERMANENT ADDRESS IN INDIA
1-13-200, YANAM, YANAM
Address
YANAM, PUDUCHERRY
PIN 533464
Mobile/Tel No. 9490353749
E-mail SKVSKRAJU@GMAIL.COM
PRESENT ADDRESS IN COUNTRY OF DOMICILE
R17C, EZDAN30, AL WUKAIR
Address
, QATAR
Mobile/Tel No. 97433773610
OTHER DETAILS
Have you ever been charged with criminal proceedings or is any arrest
NO
warrant/summon pending before a court in India?
SELF DECLARATION
I owe allegiance to the sovereignty, unity and integrity of India, and have not voluntarily acquired citizenship or travel document of any other
country. I have not surrendered or been deprived of the citizenship of India and I affirm that the information given by me in this form and the
enclosures is true and I am solely responsible for its accuracy, and I am liable to be penalized or prosecuted if found otherwise. I am aware that
under the Passports Act, 1967 it is a criminal offence to furnish any false information or to suppress any material information with a view to
obtaining passport or travel document.

Place QATAR
Signature/Left Hand Thumb Impression of Applicant
Date 27/08/2019