PSI PCC No. DATE OFFICE OF THE ADDL. COMMISSIONER OF POLICE SPECIAL BRANCH, C. MUMBAI APPLICATION FOR POLICE CLERANCE CERTIFICATE BY AN INDIAN PASSPORT HOLDER SURNAME NAME ‘Name of the applicant with aliases if any (CIN BLOCK LETTER ) Father / Husband's Name Present Address (10 be verilied where stayed for more than one year ) Telephone No. Local Police Station _ Period of staying in Mumbai Since Particulars of the places (with period of residence) where you have resided during proceeding years since birth Information of NAME y 2 OCCUPATION PRESENT ADDRESS 1_| FATHER it | Me HUSBAND WIFE _| BROTHER SISTER Date of Birth Place of Birth Educational Qualification showing places of education with years in School / Collages Present Occupation/Service with all particulars Reasons for obtaining Police Clearance Certificate for which Country Particulars of Passport Passport No. Date of Issue Place of Issue Valid DateI] | Have you ever been arrested Prosecuted / Convicted / Detained ? If so, give particulars 12 | Have you ever taken active part in Politics ? Ifo, give particulars 13 | Identification Mark 14 | Name and addresses of two responsible [ 1) persons of your locality to whom you are known 2) I certify that the forgoing information is correct and complete to the best of my knowledge and belief. Place : Date: (Signature of the Applicant ) Note: Application should submit the photocopies of the following documents duly attested by Gazzeted Officer or First Class Magistrate 1, Attested Xerox copy of Valid Passport & 2 passport size photographs. Atested Xerox copy of Residential Proof ( In addition to passport) ie. Ration Card/ Societies Letter/ Electricity Bill / Telephone Bill, etc 3. Letter/instructions of the Embassy demanding the Police Clearance Certificate. 4. A Demand Draft of Rs. 100/- in favour of "COMMISSIONER OF POLICE, BRIHAN MUMBAI" as a charges for verification to be paid to the Government Rv FOR OFFICE USE ONLY Verified by PSI Police Clearance Certificate No. Date of Issue Seal of the Issuing Authority