POLICE CLEARANCE CERTIFICATE APPLICATION FORM

To
The Superintendent of Police,
District Police Office,
Ambala.
Subject: Application for issuance of PCC
Sir,
It is requested that a Police Clearance Certificate
may be issued to me for visa/immigration purpose. My

Applicant must paste

one photograph 35mm x
35mm here with half the
signature
on
the
photograph and half on
the application.

personal particulars are as follows:

Full Name (Expanded Initials) __________________________________________
Sex _______________________________________________________________
Previous Name (in case the name has been changed) ________________________________
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.
____________________
(Signature of Applicant)
_________________
(Date)

Documents attached: _______________________________________________