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Affidavi
(U/S 7(2) of the Private Security Agency(Regulation) Act, 2005)
I---------------------------------S/O--------------------------------Age--------------------R/O Hereby solemnly declares
(1) That I am citizen of India.
(2) That I have not been convicted by any court of law in India or abroad for an offence in
connection with
promotion, formation or management of any company(any fraud or misfeasance committed by
me in relation to any
company.
(3) That I have not been convicted by any court of law in India or abroad for an offence
prescribed punishment for
which imprisonment of not less than two years.
(4) That I have no link whatsoever with any organization or association which is banned under
any law or account
of their activities which pose threat to the national security or public order.
(5) That there is no case or information registered against me in the Police or with other
competent authorities for
committing or abetting the activities which are prejudicial to national security or public order.
(6) That I have not been dismissed or removed from any government service on the grounds of
misconduct or
moral turpitude.
(7) That my company/Firm/association is registered in India and no proprietor or majority
share holder as partner
or director in this company/Firm/association is citizen of country other than India.
(8) That I will ensure the availability of training prescribed for the security guards and
supervisors.
(9) That I will abide by theconditions of the licens
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FORM 1
(See rule 3)
Form for verification of Antecedents of Applicant
Thumb Impression of the Applicant...............................
Signature of the Applicant..............................................
Passport size recent
Photograph attested
by Class1 Gazetted
Officer
Form Number
Date
2.
If you have ever changed your name, please indicate the previous
full ............................................................................
3.
Sex (Male/female)..................................................
4.
Date of birth............................................................
5.
name(s) in
6.
Father's full name/legal Guardian's full name (including surname, if any) (Initials
not allowed) ...........................................................
7.
Mother's full name in block letters (including surname, if any):(Initials not allowed)
.............................................................
8.
If married, full name of spouse in block letters (Including surname, if any): (Initials
not allowed)......Smt. Shuchi Sawhney .....................................
-29.
-317.Have your at any time been convicted by a court in India for any criminal of sentenced
to imprisonment ? If so, give name of the court, case number and offence (attach copy of
Jugment).
......................................................................................................
18. Are and criminal proceeding pending against you before a court in India ? If so, give
name of court, case number and offence.
..........................................................................................................................................
....................................................................
19. Self-Declaration :
The information given by me in this form and enclosures in true and I am solely responsible
for accuracy.
(signatur/T.I. of applicant)
Date...........................
Place...........................
20. Enclosures :
.............................................
...............................................
(signatur/T.I. of applicant)
(Left Hand Thumb Impression if Male and Right Hand Thumb Impression if Female)
For Office use only
File No...........................................
Date of issue of Character and Antecedents Report............................
(signature of Police station in charge)
Name of Police Station..............................
Name of District......................................
N.B. Cancel whatever is not applicable.
1.
2.
3.
5.
Whether applicant have been convicted by any court.
S.N. FIR
Case
Name
Name
Section Date Of
NO.
No
of
of
Of Law Judgment
Police
Court
station
Yes/No
Whether
Discharged/
Acquitted/
convicted
6.
Yes/No
7.
8.
9.
10.
Yes/No
Yes/No
Yes/No
Yes/No
Date.
Form-V
(See rule 8)
2.
3.
Son/Wife/daughter of :---------------------------------------------
4.
5.
6.
7.
Name and addresses of Proprietor, partner, Majority shareholder,
Director and Chairman of the Agency.---------------------------------------------- ------------------------------------------------------------------------------------------8.
9.
-210.
(a)
(b)
(c)
(d)
15. Does the applicant possesses the training facility in its own or will get
on outsourcing basis ? The name and address of training facility should be furnished.
Signature
Name of the applicant.
Address of the applicant
Telephone No- of the applicant.
Date of application.
Enclosure :
1.
2.
Other enclosures.
3.