PHOTO (Application Form for Refugees) Postage

Stamp
Rs 10/-

Additional Inspector General of Police,

Police Headquarters, Crime Investigation Department, Naxal, Kathmandu

Subject: Request to Provide Character Certificate

Dear Sir/Madam,
I, hereby, submit the application for Character Verification Certificate and certify that the information provided
herein are true. I have attached the necessary documents for verification.

I fully understand the consequences of providing the false information.

Note: - Use Capital Letters only

1. Full Name: - Mr. / Mrs. / Miss …………………………………………………………………………………………………………..
2. Father / Husband’s Name: - Mr. ……………………………………………………………………………………………………
3. Male / Female: - ……………..
4. Nationality: - ………………..
5. Date of Birth: - A.D………………………
6. Permanent Address: - Country……………… Province/State…………………City……………. Street/Zip code ………………
7. Address in Nepal: - District …………………Metro. /Sub. Metro/Muni./V.D.C…………………………………Ward No………
8. Refugee ID No/ Card No: - ……………………………. Issuing Office:-……………………………………………….
9. Travel Document/Passport No: - ………………..…… Issuing Country: - ………………………………………......................
10. Travel Doc/Passport Issuing Date: - ……………………..Expiry Date:-……………………………………………………….
11. Stayed Period in Nepal: - From………………………………..To………………………………………………………
Applicant (Relative/Organization) Applicant's Finger Print

Signature:-
Name:-
Date:-
Phone No/Email Address:-
Right Left

For Official Use Only

Centre: - Registration No.:- Distribution No.:-

Certifying Authority Record Examiner (CRS) Final Examiner (Character Verification

(Registration Centre Head) Section)

Name and Designation :- Name and Designation :- Name and Designation :-

Signature:- Signature:- Signature:-

Result:- Correct Incorrect Signature of Section Head

Signature of Section Head