Police Verification Form AE

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XvKv cvIqvi wWwweDkb Kvvwb wjwgUW

cvK PvKzwi ev hvPvB dig


cv_x h c` wbqvwRZ neb m c`i bvg t mnKvix cKkjx|

1g fvM
(cv_x wbR c~iY Kwieb)
1| WvK bvg _vwKj Zrmn c~Y bvg (vi), RvZxqZv I gvevBj b^i
t.............................................................................
2| wcZvi I gvZvi c~Y bvg I RvZxqZv t
.......................................................................................................................
3| vqx wVKvbv (A_vr Mvg, WvKNi, DcRjv I Rjv)
t .....................................................................................................
4| eZgvb evmvbi wVKvbv
t .......................................................................................................................................
5|

cv_x h me vb weMZ cuvP ermi Qq gvmi AwaK emevm KwiqvQb mme vbi

wVKvbv t
wVKvbv

ZvwiL nBZ

ZvwiL ch

6| Rb ZvwiL (gvawgK zj mvwUwdKU/ mggvbi cixvi mvwUwdKU Abyhvqx)


t .................................................................
7| Rbvb (Mvg, cv:, DcRjv, Rjv BZvw` DjL KwiZ nBe)
t ...................................................................................
8|

cv_x cbi ermi nBZ hB me we`vjq, gnvwe`vjq I wekwe`vjq Aaqb KwiqvQb


mBme wkv cwZvbi bvg I ermi DjLc~eK wkvMZ hvMZv t
we`vjq, gnvwe`vjq,
wekwe`vjq BZvw`i bvg

9|

Gm.Gm.wm/
GBP.Gm.wm/
MvRyqkb/ cvMvRyqkb wWMxi
iwR: b^i/ ivj b^i

fwZi ZvwiL/
ermi/ mkb

cwiZvMi
ZvwiL/ ermi

Kvb Awdm ev eemv cwZvb cv_x c~e PvKzix Kwiqv _vwKj/ eZgvb KgiZ
_vwKj Dnvi c~Y weeiY I wVKvbv Ges mBwj cwiZvMi KviY t
Awdm/ eemv
cwZvb Gi bvg

ZvwiL nBZ

ZvwiL ch

KgiZ _vwKj
(KgiZ wjwLZ
nBe)

cwiZvMi KviY

evsjv`k mbvevwnbxi Aaxb cv_x c~e PvKzix Kwiqv _vwKj, AevnwZ


mvwUwdKU wjwce PvKzixi gqv`, wK wK `vwqZ cvjb KwiqvQb Ges Pwi I AvPvieenvi mwKZ wicvUimswk weeiYvw` DjL KwiZ nBe|
10| dR`vix Kvb gvgjvq `wZ Ges Rvwgb AvQb wK-bv, ZvwiLmn c~Y weeiY w`Z nBe t
11|

cv_x
gywhvvi
bv : ................................................

cy-Kbv/

cy-Kbvi

cy-Kbv

wK-bv

(nuv/

12| cv_x gywhvv/ knx` gywhvvi cy-Kbvi cy-Kbv mbvKiY cwZ msv (chvR
):

2
w
gK
b
^i

cv_xi bvg, cv_xi wcZv


Ges gvZvi bvg

gywhvv/ knx`
gywhvvi bvg

gywhvv/ knx`
gywhvvi mv_
cv_xi mK
[wcZvi wcZv (`v`v)/ /
wcZvi gvZv (`v`x)/
gvZvi wcZv (bvbv)/
gvZvi gvZv (bvbx)]
(chvR )

ge

[cv_x gywhvv/ knx` gywhvvi cy-Kbv/ cy-Kbvi cy Kbv nBj cywjk fwiwdKkb
digi mwnZ Zvnv`i wcZv/ gvZv/ wcZvi wcZv/ wcZvi gvZv/ gvZvi wcZv/ gvZvi gvZv
(chvR ) Gi gywhvv mvwUwdKU, hvnv h_vh_fve Dchy KZc KZK
^vwiZ I cwZ^vwiZ nBZ nBe, Gi mZvwqZ Kwc `vwLj KwiZ nBe|
cv_x gywhvv/ knx` gywhvvi cy-Kbvi cy-Kbv nBj cv_x h gywhvv/ knx`
gywhvvi cy-Kbvi cy-Kbv GB gg mswk BDwbqb cwil`i Pqvigvb/ wmwU
Kcvikbi IqvW KvDwji I cimfvi gqi/ KvDwji KZK c` mvwUwdKU G digi
mwnZ mshy KwiZ nBe|
gywhvvi cy-Kbv, cy-Kbv`i cy-Kbv wnme Ave`bKvix cv_x`i wcZv/ wcZvgni
gywhvv mb` DwjwLZ wVKvbvi mv_ Ave`b c DwjwLZ vqx wVKvbv nZ wfb nj
cwiewZZ vqx wVKvbvi ^c mswk wmwU Kcvikbi gqi/ IqvW Kwgkbvi/
cimfvi gqi / BDwbqb cwil`i Pqvigvb/ bvUvix cvewjK KZK ^vwiZ cZqbc Rgv
w`Z nBe|]
13| wbKU AvZxq-^Rbi Kn A_vr fvB, fwM, Avcb PvPv, kii w`Ki wbKU AvZxq-^Rb
evsjv`k miKvii PvKzixZ wbhy _vwKj, c`i bvg I Kgvb DjLc~eK c~Y weeiY t
AvZxq-^Rbi bvg

c`i bvg

Kgj

14| cv_xi Pwi I c~e cwiPq mK mv w`Z cvib wK cv_xi mwnZ AvZxqZv m~
Ave bnb Ggb `yB ewi wVKvbvmn bvg (msm`-m`m, wmwU Kcvikb Gi gqi, WcywU
gqi I KvDwjiMY, c_g kYxi Awdmvi, wekwe`vjqi wkK, DcRjv cwil`i Pqvigvb I fvBm
Pqvigvb, cimfvi gqi I ci KvDwjiMY, BDwbqb cwil`i Pqvigvb, emiKvix gnvwe`vjqi
Aa Ges emiKvix DP we`vjqi cavb wkK) t
bvg

15|

(K) weevwnZ ev AweevwnZ : weevwnZ

wVKvbv

AweevwnZ wWfvm

mcvikb

Abvb

(L) weevwnZi ^vgx/ xi bvg:


Avwg kc_c~eK ewjZwQ h, Dci c` weeiYmg~n Avgvi RvbvgZ mwVK| wg_v Z_i
Rb cv_xZv evwZjmn Avgvi wei Abvb eev bIqv hvBZ cvi|

evg nvZi evywji


Qvc Ges
RvZxq cwiPqci b^i:

Memo no.: DPDC/HR/DGM (A)/ Appointment/Officer/ 2012/

cv_xi ^vi

Date:

/2015

AeMwZ I KvhKix eev MnYK, cywjk mycvwibUbWU/Rjvi kvj cywjk ev/kvj evi
WcywU Bci Rbvij Ae cywjk/kvj ev/ .................................................. mswk cv_xi

3
cywjk fwiwdKkb dig h_vh_ Z` KiZt Riix wfwZ A Awdm diZ cvVvbvi Rb weklfve
Abyiva Kiv hvBZQ|

gvnv: gwbivgvb
wWwRGg, Ggcqx gvbRgU
(AvW&&wgwbm&&UBkb)
wnDgvb wimvmm|

2q fvM

(Rjv kvj cywjk mycvwibUbWU/ evsjv`k kvj evi WcywU Bci Rbvij Ae cywjk
c~iY Kwieb)|
Dchy t
wbgv KviYi Rb Abychy t
vb .........................................
Rjv kvj ev/

cywjk mycvwibUbWU,
WcywU Bci Rbvij Ae
cywjk, kvj ev, evsjv`k|

ZvwiL ......................................

UxKvtcZqb mswk cv_xi wei Kvb wKQz bv cvIqv Mj, Rjv kvj evi
cywjk mycvwibUbWU/ evsjv`k kvj evi WcywU Bci Rbvij Ae cywjk Revemn
GB digwU ciYKvix KZci wbKU mivmwi diZ cvVvBeb| wK hw` mswk cv_xi
wei iKW Kvb Z_ cvIqv hvq Zvnv nBj, Rjv kvj evi cywjk
mycvwibUbWU, evsjv`k kvj evi GwWkbvj Bci Rbvij Ae cywjk Gi gvag
Revemn GB digwU ciYKvix KZci wbKU diZ cvVvBeb|
cwZ^vwiZ ..........................
....
cywjk,

GwWkbvj

Bci-Rbvij

kvj ev, evsjv`k, XvKv|

Ae

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