Police Clearance Certificate Application Form
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1
2POLICE CLEARANCE CERTIFICATE APPLICATION FORM
To
The Superintendent of Police,
District Police Office,
Yamuna Nagar.
Applicant must paste
one photograph 35mm
x 35mm here with half
Subject: Application for issuance of PCC
the signature on the
photograph and half
Sir,
It is requested that a Police Clearance Certificate
may be issued to me for visa/immigration purpose. My
personal particulars are as follows:
Full Name (Expanded Initials)______________________________________________
Sex ___________________________________________________________________
(in case the name has been changed)
Previous Name
_____________________________________
Date of Birth____________________________________________________________
Occupation _____________________________________________________________
Father (Full Name) _______________________________________________________
Mother (Full Name) ______________________________________________________
Spouse (Full Name) ______________________________________________________
Permanent Address _______________________________________________________
_______________________________________________________________________
Present Address _________________________________________________________
Residing at current address since ____________________________________________
Passport No. _________________ Date of issue __________ Valid till______________
Passport issued by: Regional Passport Officer __________________________________
Country for which Visa/Immigration has been applied ___________________________
It is further stated that I am a citizen of India and have not been involved in any
criminal case in India and that there is no criminal case pending against me in the Court
of Law.
_____________________
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