Form n

See rule 4)

Form for verification of Character and antecedents Of Security

Guard and Su~rvisor

Thumb Impression * of the Applicant Passport Size recent

Photograph a~ by
Signature of the Applicant ~ Class I Gazetted Officer

F or official use only

Form number Name of the police,station send for police Date

verification

Date
Fee
Name
PleaseAmount
of of Issue
rend
Bank Rs.the instructions Cash carefully
/D.D D.D. No.before rdling the form. Please rill in

BLOCK LETTERS: (CAunON: Please furnish correct information. Furnishing

of incolTect information or suppression of any factual information in the form

will render the candidate unsuitable for employment /engagement in the Private

Agency.)

1. Name of applicant as should appear in the photo-identity card

(Initials not allowed)

Last
2. If you
name have ever changed
First name
your name, please indicate the previous name(s) in full

---~ Sex
3. (male/female).
c 4.Date of Birth:
t"'
 District,
6.
5. Place
Father's of Birth:
Full Name/
Village Legal
/ Town
State Guardian's
&Country Full Name (including surname, if any)

7(Initials
Mother's not Full
allovved)
Name (including surname, if any). (Initials not ,;;b.

a
II
ovve
d) ~;i:,.
~'~~
;c~""'
.. ,

8. Ifmarned, Full Name of Spouse (including surname, if any).

(Initials not allovved)

9 Present Residential Address, including Street No./police statio~ village and District
(vvith PIN code)

Telephone
10. PleaseNogive
!'Mobile
the No
date since residing at 1e ove mentioned address

DD/MM!..f'YYY

11 Pernlanent Address including Street No. .,~ ;~',);-, \;IJlage and District (with
PIN code )
,--
 12. If you have not resided at the address wven at COLUMN (9) continuouslv for th
'c last five Year. Rlease furnish the other address (addresses) with duration(s) resid.
You should furnish additional DhotocoDies of this form for each additional Dlace of
~ during the last five year. Forms m~ be QhotocoQied. but Qhoto~aDh and
signature in oriWal are reouired 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 posts held along with name and address of employer

( c) Reason for leaving last employment "---"'--'"

( d) Visible Distinguishing
" """ Mark

(e)Height(cm'3).,- f.

.G~L I t
15. Are you working in Central Government! State Govt/ PSU/ Statutory Bodies
Yes/No

16. Are you a citizen of India by: Birth/DescentlRegistrationlNaturalisationIf you

have ever possessedany other citizenship. pleaseindicate previous citizenship

17. Have you at any time been convicted by a court in India for any criminal offence
& sentencedto imprisonment?if so, give nameof the court, casenumber and offence.
(Attach copy of judgment)

18. Are any criminal proceedingspending againstyou before a court in India? If so,
give name of co~ casenumber and offence

19. Has any court issueda warrant or summonsfor appearanceor WaITantfor arrestor
an order prohibiting your departurefrom India? If so. give nameof court, casenumber
and offence.

20. Self Declaration:

The infonnation given by me in this form and enclosuresis true and I am solely
responsiblefor accuracy.

(Signature/T .L * of applicant)

(*Left Hand Th~b Impression ifMale andRight Hand Thumb Impressioniff emale)

Place
Date '1l]- &" ,-C)If2

'S 3A
21. Particulars of person to be intimated in the event of death or
accident:

Name
Mobilerrel.
Address No. :

22 Enclosures: ,

(Signature I T .L or applicant)

*FOR OFFICE USE ONLY

File No.: : .

Date of issue of C&A Report. .

(Signature ofPolice station In charg~)

Name ofPolice Station

Name ofPolice district

~ N.B. Cancel entries not applicable.

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