Form II (See Rule 4) Form for verification of Character and ...
Form II (See Rule 4) Form for verification of Character and ...
Form II (See Rule 4) Form for verification of Character and ...
- No tags were found...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>Form</strong> <strong>II</strong>(<strong>See</strong> <strong>Rule</strong> 4)<strong>Form</strong> <strong>for</strong> <strong>verification</strong> <strong>of</strong> <strong>Character</strong> <strong>and</strong> Antecedents <strong>of</strong> Private Security Guard <strong>and</strong>Supervisor.Thumb impression* <strong>of</strong> the Applicant __________________________Signature <strong>of</strong> the Applicant _________________________________Passport Sizerecentphotographattested byGazettedOfficer<strong>Form</strong> NumberFor <strong>of</strong>ficial use onlyName <strong>of</strong> the police station to which sent <strong>for</strong>police <strong>verification</strong>DateFee Amount Rs. ______________________ Cash/ D.D.____________________Name <strong>of</strong> Bank ______________________ D.D. No. ______________________Date <strong>of</strong> Issue ________________________Please read the instructions carefully be<strong>for</strong>e filling the <strong>for</strong>m. Please fill in BLOCKLETTERS: (CAUTION: Please furnish correct in<strong>for</strong>mation. Furnishing <strong>of</strong> incorrectin<strong>for</strong>mation or suppression <strong>of</strong> any factual in<strong>for</strong>mation in the <strong>Form</strong> will render thec<strong>and</strong>idate unsuitable <strong>for</strong> employment/engagement in the Private Agency.1. Name <strong>of</strong> the applicant as should appear in the photo-identity card (initials notallowed)Last Name _________________ First Name ___________________2. If you have ever changed your name, please indicate the previous name(s) infull ______________________________________________________.3. Sex (male/female) ______________________
4. Date <strong>of</strong> Birth ___________________________5. Place <strong>of</strong> Birth: Village/Town ____________________________________District, _____________________ State & Country __________________6. Father’s Full Name/Legal Guardian’s Full Name (including surname, if any);(initials not allowed)_____________________________________________________________7. Mother’s Full Name (including surname, if any): (initials not allowed)_____________________________________________________________8. If married, Full Name <strong>of</strong> Spouse (including surname, if any) (initials not allowed)__________________________________________________________________________________________________________________________9. Present Residential Address, including Street No./Police Station, village <strong>and</strong>District (with PIN Code)_______________________________________________________________________________________________________________________________________________________________________________________Telephone No./Mobile No. ________________________________________10. Please give the date since residing at the above-mentioned address: DDMM YY_____________________________________________________________11. Permanent Address including Street No./Police Station, village <strong>and</strong> District (withPIN Code)__________________________________________________________________________________________________________________________
12. If you have not resided at the address given at COLUMN (9) continuously <strong>for</strong> thelast five years please furnish the other address (addresses) with duration (s)resided. You should furnish additional photocopies <strong>of</strong> this <strong>Form</strong> <strong>for</strong> eachadditional place <strong>of</strong> stay during the last five years. <strong>Form</strong>s may be photocopied, butphotograph <strong>and</strong> signature in original are required on each <strong>Form</strong>.From …………….. To ……………. From ……………… To …………………__________________________________________________________________________________________________________________________13. In case <strong>of</strong> stay abroad particulars <strong>of</strong> all places where you have resided <strong>for</strong> morethan one year after attaining the age <strong>of</strong> twenty-one years._______________________________________________________________________________________________________________________________________________________________________________________14. Other Details :(a)(b)Educational Qualifications:_________________________________________________________________________________________________________________________Previous positions held, if any, along with name <strong>and</strong> address <strong>of</strong> employer:__________________________________________________________________________________________________________________________(c) Reasons <strong>for</strong> leaving last employment :__________________________________________________________________________________________________________________________(d)(e)Visible Distinguishing Mark : ______________________________________Height (cms) __________________________________________________15. Are you working in Central Government/State Govt/ PSU/ Statutory Bodies. Yes/No._____________________________________________________________16. Are you a citizen <strong>of</strong> India by: Birth/Descent/Registration/Naturalization:If you have ever possessed any other citizenship, please indicate previouscitizenship _____________________________________________________
_____________________________________________________________17. Have you at any time been convicted by a court in India <strong>for</strong> any criminal <strong>of</strong>fence<strong>and</strong> sentenced to imprisonment ? If so, give name <strong>of</strong> the court, case number <strong>and</strong><strong>of</strong>fence. (Attach copy <strong>of</strong> judgment)_____________________________________________________________18. Are any criminal proceedings pending against you be<strong>for</strong>e a court in India? if so,give name <strong>of</strong> court, case number <strong>and</strong> <strong>of</strong>fence._______________________________________________________________________________________________________________________________________________________________________________________19. Has any court issued a warrant or summons <strong>for</strong> appearance or warrant <strong>for</strong> arrestor an order prohibiting your departure from India ? If so, give name <strong>of</strong> court, casenumber <strong>and</strong> <strong>of</strong>fence .__________________________________________________________________________________________________________________________20. Self – Declaration:The in<strong>for</strong>mation given by me in this <strong>for</strong>m <strong>and</strong> enclosures is true <strong>and</strong> I am solelyresponsible <strong>for</strong> accuracy.(Signature/T.I* <strong>of</strong> applicant)(*Left H<strong>and</strong> Thumb Impression if Male <strong>and</strong> Right H<strong>and</strong> Thumb impression if Female)Date ………………Place ……………..21. Particulars <strong>of</strong> person to be intimated in the event <strong>of</strong> death or accident :Name _______________________________________________________Address _____________________________________________________Mobile/Tel. No. _______________________________________________22. Enclosures :________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________(Signature/T.I* <strong>of</strong> applicant)(*Left H<strong>and</strong> Thumb Impression if Male <strong>and</strong> Right H<strong>and</strong> Thumb impression if Female)FOR OFFICE USE ONLYFile No. : …………………………………………………………Date <strong>of</strong> issue <strong>of</strong> C& A Report ………………………………….(Signature <strong>of</strong> Police Station in charge)Name <strong>of</strong> Police Station ____________________________________Name <strong>of</strong> Police District ____________________________________* N.B. Cancel entries not applicable.
Change language