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ANNEXURE -I

( SECURITY VERIFICATION QUESTIONNAIRE FOR WORKERS OF CONTRACTORS

01. Name

02 . Father's/Husband's Name

03. Local Address: House No. - - - Street:--------------

Village: - - - - - -- - PO:_ _ _ _ _ _ _ PS: - -- - - -- - - -

Dist.: State: - - - - - - - - - - - - - - - - -

04. Native Address: House No. _ __ Street:---- - - - - - - - - --

Village: - - - - -- - - PO : - - - - - - - PS: - - - - - - - - - -

Dist. : State: - - - - - - - - - - - - -- - - -

05. Nationality: _ _ __ _ _ _ _ _ Religion: _ _ _ ____:__ _ _ _ _ _ _ __

06. Identification Marks:

a) _ _ _ _ __ _____ ____________ b) ____________________

07. Name of the Contractor/Company by whom employed presently: - - - -- - - -

Full address of the Contractor I Company with telephone No.

08. Full address of the places in which I have resided for more than one year:

09. Full address of the previous employer and the details of employment

10. a. I have been arrested Yes/No.

b. I have been prosecuted Yes/No.

c. I have been kept under detention Yes/No.

d. I have been fined by Court of Law Yes/No.

e. I have been convicted by court of law Yes/No .

Note: If for any item, if it is stated ' YES' the full details should be furnished :

..
b. Particulars of pending cases in any Court of Law:
 11. Name and address with telephone nos. of two responsible persons of your locality or two references
to whom you are known:
(
1. ____________________________________ 2. ___________________________________

I certify that the foregoing information is correct and complete to the best of my knowledge and
belief.

Place: Signature of Worker

Date : & Thumb impression

Certified that the above person will be engaged by me to carry out the work awarded to me
under work order No. date ___________

Signature of the Contractor

(with seal)

Certified that the work order No. ---------------------------------------dated

--- - - - for (Nature of
work /Contract) has been awarded to (Name &
Address of the Contractor).

Signature of the Engineer-in- Charge Signature of the Section Head

(with seal) (with seal)

Manager (SA & OL)

CONTRACT LABOUR ANTICIDENT VERFICATION

1. The particulars, character and antecedents of Shri/Smt/Ms. - - - - ---- - -------------------

been verified by CCTNS.
2. Nothing adverse against him/her noticed
3. The following remarks /observations are made:

4. Photo and address is verified by 1) Ration Card/ 2) Adaar Card/ 3) Voter ID Card/ 4) Driving Licences I
any Bank Pass book

Deputy Superintendent of Police, Inspector of Pt>lice Sub-Inspector of Police

Mamallapuram sub- division,
Mamallapuram.