Application For Police Clearance Certificate
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3Reference No: …………………..
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APPLICATION FOR POLICE CLEARANCE CERTIFICATE
POLICE HEADQUARTERS, COLOMBO 01, SRI LANKA
(PLEASE WRITE ALL IN CAPITALS)
1. Applicant’s
Name in full:
2. NIC Number :
3. Reference High Commission/Embassy :
4. Passport Number:
5. Nationality:
6. Date of Birth :
Sex:
Male
Female
7. Occupation:
8. Purpose
:
Residence Visa
Temporary Visa
Employment
Student
Scholarship
9. Status : Rev.
Married
Unmarried
10. Have you applied for a certificate previously?
Yes
No
Country
11. If so, was a certificate issued to you:
Yes
No
Date of issue:
Reference No:
12. Present address
in Sri Lanka:
13. Present address:
(Overseas)
14. Places of residence for the period certificate is required:
(If insufficient space, give details on an attachment)
Date
Addresses
Police Area
From
To
* If police area incorrectly filled, your clearance certificate could delay.
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