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qrr.; ;:f, ~ ~ m:r ~ q51"tfm uffiT ~ ·.- tRci . ~ cfITTf ~ 11m t cf>ISMI~ mt ~&R ~ ~ m,s:i~11'(/~ ~ ~ ·m:IT ~/3ff;J -~ ~ w~ ,mn,-7rnrt " -<l~lllc1I ~ "QRll m-r r$1· ~- -o/i~ 31~ 1f PlgRre/ ~ mt ~ t1i:i,~' ml~-Q • ~13~) . ' ' ~ " . - .
~ Pllll\11--1 ~ cf)T -;;r:J: ............................................... : ............ ..
~ ~ cf>l'"l'll'</~ cf5T .:ni:J: ................................................ ...
~ ~: ........................... ~ ............... ~ ..... :.: .............................. : .......... .
~ cf>l&i' II~/~ cnT ~ cfil,fcfi: .......................................... .
~fflcfft~: ................................................................ : .................. ..
~ ~: ..................................... , ...... : .................................................. cfcp m ~ cf5T ~l¼R: ......................................................... : ................... .
92,4 (21) ' ' ~ q;y Q>lcBlllf> ~ ffl qffi ~GRT~ ~ ~ S4'11fata ~ 924 (22) ~.~2JWT«{21114 . ~"C!to 2-ss/m-~/~/2013. -~·t.maUR~~ 34sifi~:(3)ifi~ii ~fumrr<ft w~ . fUH-i@¾> ~ 21-Q8-2014 <fil .mral ~ ~ ifi ~ ~ ~ ~ f-v.n ~l Raipur, the 21st August 2014 NOTIFICATION No. F 2-58/Two-Home/2013. - In exercise of the powers conferred by sub-section (I) of Section 12 of the Chhattisgarh Private Placement Agencies · (Regulation) Act, 2013 (No. 23 of 2013), the State Government, hereby, makes the following rules for regulating Private Placement Agencies and matters connected therewith or incidental thereto, namely:- ' RULES ' 1. Short title, extent and commencement.-'- ( 1) These rules may be called the Chhattisgarh Private Placement Agencies (Regulation) Rules, 2014.
(2) These rules shall be applicable in the whole State of Chhattisgarh.
(3) These rules shall come into force from the date · of its publication in the Official Gazette.
2. Definitions.-:. ( 1) In these rules, unless the context otherwise requires,-
(a) "Act" means the Chhattisgarh Private Placement Agencies (Regulation) Act, 2013 (No. 23 of 2013);
· (b) "Agency" means a Private Placement Agency as defined under clause (h) of Section 2 of the Act;
(c) "Appellate Authority" means the Principal Secretary, Department of Home, Government of Chhattisgarh;
.. .,.. . ..,.
i "I 924 (23)
(d) "Authorized ·officer" means any officer authorized by the Controlling_Authority;
(e) "Controlling Authority" means the District Magistrate of the concerned district;
(0 "Form" means Fo'rms appended to these rules;
(g) "Licensing Authority" means an officer or authority empowered to grant or renew licenses under these rules;
(h) · "Licensee" means the · agency to which license has beeri granted under the Act.
(2) Words and expressions used 1n these rules but not defined shall have the same meaning as assigned to them in the Act.
3. Manner of making application for grant and renewal of license.- (1) Every application by an Agency for .the grant of a license un_der sub-section (1) of Section 5 of th·e Act shall be m~de to the Controlling Authority in Form-I.
(2) Every application refe~red to in sub-rule ( 1) shall be submitted alongwith fee, in the form of crossed bank draft/ demand draft or ' banker's cheque payable to the Controlling Authority, as under:- . .
(a) If the Private Placement Agency is op<=:rating in one district, then agency has to furnish fee of -rupees five thousand along with bank guarantee of rupees ·one lakh;
(b) If the Private Placement Agency is operating in more than one district but not exceeding five districts, then agency has to furnish fee of rupees five thousand along with bank guarantee of rupees one lakh;
....
' 924 (24) ~3dh-M<$ ~. ~ 2 t WI«'! 2014
(c) If Private Placement Agency is operating in the whole of the state, then the agency has to furnish fee of rupees twenty five , .
thousand along with hank guarantee of rupees <_>ne lakh;
(3) Every application referred to in sub-rule ( 1) shall be either . . .
delivered personally to the Controlling Authority or through a representative.
(4) On receipt of the application referred to in sub-rule -(1), the Controlling Authority shall after noting the· date of receipt of the .
application, provide an acknowledgement to the applicant
4. Verification of character and antecedents of the applicant. -
(1) Every applicant while making an application to the Controlling Authority for issue of fresh license or renewal shall enclose with the application Form-II for verification of its antecedents. In case, the applicant is a company or a firm, separate Form-II for every proprietor, majority shareholder, partner or director, as the case may be, shall be enclosed, as if they are also the applicants.
(2) On receipt of the application· the Controlling Authority or Authorized Officer may, for verification of the contents of the application, forward it to the Superintendent of Police of the concerned district where the agency intends to -.~ommence its activities and make such inquiry as he considers nec_essary for verification of particulars ·of the a,ppJicant .
. '(3) After ·verificatibn, the -Corttr.olling Authority or any: Officer Authorized~byrhim shall o_btain:-
(a) No 'Objec'tioh:Cet(ificate from 'the concerned Superintendent , of Police;
, , .... "' .:::::-4 924 (25)
(b) The verification report shall be prepared by Supenntenae11L of Police, in which particulars of the applicant and every ·person in whose name the antece.dent form is ·filled up.
(4) The Superintendent of Police of the concerned police district shall furnish the no ·objection certificate within thirty days of receipt of the application to the Controlling Authority or any other Authorized Officer for the said-purpose.
(5) The Superintendent of Police shall also furnish the verification report within thirty days of receipt of the application to the Controlling Authority or the Authorized, Officer containing the following information; namely: -
(a) ·Whether the applicant is/ was indulged in activities which· are prejudicial to national security or public order and if SO;
details thereof,
(b) Whether the applicant earlier operated any agency either · in.dividually or "in a partnership and if so the details thereof;
and
(c) Whether the applicant possesses any special qualificatio~\ ~ skiii which may be considered to be facilitating tqe 0,.perat~QJ:1;S.
of the agency.
S. Ve.rlficatioti of character -a~d · tA~_te~~q~nts of t~~ d.9~~lt\9 worker.- (1) No /p~s<?Jl s:tialJ b~ employed or ~ngqg~<;:\ as ~ domestic worker ~y the ~gen_cy un,less I:ie fulfills the conditions specified in s~-9ti,9n 7 of t~e Act and the agency is satisfied about the character and ?D-tec~d.ents of such person in the following mann~r ,_ n.am.ely: - 924(26) ~ .. fo'1idll?q •J~fT:f?I, ~ 21 W1tt1 2014 · (a) After verification of the character and· antecedent by 1tsen;
(b) After verification . of the character and antecedent certificate produced by the person:
Provided that the certificate is valid and the agency has no adverse report regarding his character and antecedent from any other sources;
(c) After receiving the character and antecedent report from the Superintendent of Police ..
(2) A person seeking employment as dotnestic worker shall submit the information ·in -Form-III to the agency and in case the person has stayed in more than one district during the last five ,, .
years then separate forms shall be submitted for each district.
(3) The agency may make an enquiry for veri(ying the particulars of the person seeking ·employment_ as dC?mestic worker, either by ' . .
itself or by the Authorized Officer for this purpose or may forward I Form-III to the concerned Superi~tendent of Police, as the case may be.
(4) Tht ;erson shall deposit the verification charges as prescribed in sub-rule (9) in 1 c:--oect of each individual case for verification of character and antecedent:'·. !o the concer1?,ed Superintendent of Police Or the :t\uth~rized Officer foc-::hi5 p:l!"pose.-. •,_ --
(5) The con'.~ern~d Super111t~r10.~-~t of Pclice ot. the·, AuthOrized 4 • , .. ~-t ,, ,_ . , -.,. , . ~ Officer f9r this purpose, f~r 'establishing' .the. identity and for ~ •A•• {;, _,;, .. ~•,'i•i._-..•;: j :. -~,; '>;• ••• ••~ ... :) •• =.• •• • •' ' . v_~rify1ng t.he character" and antecedents of the per~0n may ·make ~ ' '1 , s~ch incrt~iries from the "respectable residents wi'.thin t2e locality ·"-- '~-,' ,,: •. -. j 924 (27) .
. •·, · and ._ the . District Police Hea1qµarten~ and by residence, as he may consider necessary.
- ' ·, ~
(6) The concerned Superintendent.-of Police or the Authorized · Officer for this purpose shall furnish the character and antecedent verification report within ·thirty days of receipt of the Form-III to the designated officer of the agency, containing the.
following information,· namely: -
(a) The comments of the police on the particulars filled by the· person in Form-III;
(b) A general report about other activities including his I}leans of liveii.hood during the period of verification;
(c) Disclosure about -- .. !p.e criminal investigation or proceedings, registered or co:e1menced or pending or disposed of at any point of time;
(d) Regarding his conviction, if any, 1n criminal offenc~ punishable with impriso11ment;
(e) Whether the engagement or employment of the person under verification by the agency will pose a threat to national security or not.
(7) The character and antecedent verification report shall be ma:cked as confidential and forwarded in the sealed cover and shall remain valid for three years from the date of verification.
(8) On the basis of the -character · and antecedent verification report submitted by the concerned police station or the Suoerintendent of Police of the concerned district or the ..
I , -924(28) Authorized Officer for this purpose or of the agency nseu, Luc agency shall issue. a character certificate to the person in Form IV, which shall not be taken ·back even if the person ceases to be part of the agency.
(9) A fee of rupees two hundred and fifty shall be payable to the concerned Superintendent of Police or the Authorized Officer for this purpose, by way of cash or bank draft, for verifying the character and antecedents of a person to be employed by an Agency as domestic worker.
6. Grant of licence ... (1) The Controlling Authority, after receiving a report from the Authorized Officer on the applkation · received under -sub ... rule ( 1) of n.tle 3 after completing all the formalities and satisfyiftg itself a11q.µt th~ suitability of the applicant and also the need for granting license for the area of operation.applied for, $hali grant a license to the private placement agency in Form-V:
Provided that the Controlling Authority either by itself or through the Authorized Officer may verify the training and skills imparted to the private security guard, domestic workers and supervisors of any Private Placement Agency;
(2) The Controlling Authority may, after making such inquiries as it considers necessary and after,obt~ning no objection certificate - ' from tb_e concerned police authority, by order irt ~writi11:g either · gra~t ·or refu~e to ·gra.4t the license within a p;eriod of sixty days .
fro~· the ·date of' ree,eipl oi :app:lication with complete particulars and the f ee'st ,, •· "t i; .; ....
924 (29) r"j..._ • ..,_ ,l • -~q~ided that when th~ ControlJing .A:µthority _does riot agree . . . . . ·- ~-. ~ " ' .
with the no objection certificate issued from the concerned police . authority, he would briefly record the reasons of his disagreement and place the matter before the Government and proceed to grant or refuse to grant the license as per decision: of the Government:
Provided further that if the Controlling Authority decides to grant a license then he shall- grant license in Form-V. The license_ ' .
shall be valid for a period of 5 years unless the same is cancelled_ by the Cocytrolling Authority under sub-section ( 1) of section 6 of the Act.
(3)The Controlling Authority may review the continuation of license of such Private Placement Agency, which did not adhered to the conditions of ensuring the required training.
(4)The Controlling Authority shall not refuse the license unless the applicant has been given a reasonable opportunity of being heard and the ground on which license is refused is mentioned in the order.
(S)The Agency shall not use in_ its name the words like "Indian", "National" or any other such words, which give the impression of any Government patronage.
t ·• •
7. Conditions for grant of licens~.- (1) The Licensee shall intimate· the name, name of parent,. date of birth, permanent address, · Address for correspondence and the principle profession of each person forming . the Agency within fifteen days of receipt of the license to the Controlling Authority.
' ~ ..• ~c. ......
924 (30)
(2) The licensee shall inform the Controlling Authority regarding any change in the address of persons forming the Agency and · management within seven days of such change.
(3) The licensee shall immediately intimate the Controlling Authority about any criminal charge framed against the per.sons forming the Agency or the supervisor engaged or employed by the Agency, in the course of their performance of duties as private security agency. A copy of such communication shall also be sent to the officer in charge of the police station, where the accused . person resides. ·
(4) Save as provided in these rules, the fees paid for the grant of license shall be non-refundable,
8. Renewal of license.- (1) Every Agency shall apply to .the Controlling Authority for renewal of the license within period of 90 days from the date of expiry of license.·
(2) The Controlling Authority may renew a license up to a further period of five years.
(3) The fees chargeable for renewal of the license shall be same fee as applicable for the grant of license.
9. Conditions for renewal of license.- (i) The renewal of the license shall be granted subject to the following· conditions, namely:.- . .
(a) The:applicant continues to maintain hi~ principal place of ' . :,' . .:
~ ·~ · business in the.jurisdiction of the Controlling Authority.
,;-:: . ,, 'c, 1, • -1-. ' ~- I ' . : ,,.. ,. -~·: ~· .. ,••, ..
•.fatlflll~mlQ:l ~ 21 Wffif 2014. • I . • 924(31)
(b) The appiicant continues to adhere to the license conditions;
(c) The police have no objection to the renewal of the lkense of the applicant;
(2)Application for renewal of license shall also· be in Form-I.
10. Suspension or cancellation of licenses.- (1) No license granted under this Act shall be cancelled or. suspended until the licensee has been given a reasonable opportunity of being heard after giving due service of show cause as to why his license should not · be cancelled or suspended, as the case may be;
(2) No such opportunity of being heard shall be necessary on temporary suspension of license, when license is suspended temporarily pending an enquiry · against ,_,the · licensee for contravention of sub-section (1) of Section 8 of the Act or any . order made there ·under or of any of the condi!i.ons _of the license granted to him.
11. Appeals and Procedure.- (1) Any person aggrieved by any order· passed by the Controlling Authority refusing to grant a license, varying the conditions of a license, suspending or revoking a .
license may prefer an appeal against the said order to Appellate Authority.
(2) No appeal shall be entertained, unless it is submitted within a period of 90 days from the date of receiving a copy _of the order:
Provided that the Appellate Authority may entertain the appeal after the expiry of the said period, if it is satisfied that the appellant has sufficient cause for delay.
924 (32)
(3)-Every appeal under·sub-section (1') of se·ction 7 of the Act shall be pref erred in Form-VI signed by the aggrieved person or his advocate to the Appellate Authority 1n person or sent by registered post.
12 .. Register to be maintained by the Agency.- The Agency shall maintain the register in Form-VII, which shall be open for inspection by the Controlling Authority or the Authorized Officer.
13. Identity card for domestic workers.- The Agency shall issue an identity card to every domestic worker in Form-VIII, it shall contain a full-face colour-photo, name of the agency, name of the domestic worker, designation, identification number and the period of validity and the photo identity card shall be maintained upto date and any change in the particulars shall be entered therein and in a situaiion where an employee is no longer engaged or employed by the agency, the photo identity card issued to domestic worker/ supervisor shall be returned to the agency issuing it, once domestic workers is no longer engaged or employed by it.
Bv order and in the name of the Governor of Chhaltisgarh.
- I) K. MATIIUR. Deputy Se~rctary.
I ,,.
To Form-I (See rule 3) APPLICATION FOR NEW LICENCE/RENEWAL OF LICNECE TO ENGAGE IN THE BUSINESS OF PRIVATE PLACEMENT AGENCY • The Controlling Authority The undersigned hereby applies for obtaining a license to run their business in the area of Private Placement Agencies:
1. Full name of the applicant
2. Naticmality of the applicant
3. Son/ O~ughter / Wif~ of 4 .. Re~idential Addreas s. A.ddxes~ where.the applicant desires.to start·his Agency
6.. Name of th~ private placement Agency (:NOTB ~ R(}gi~tration Nurnl:>e:r of t;he Agency also be indicated) . .
1. Name arid J\c\qress of Proprietor, Partner, Majority shareholder, I Director and, Chairman of the Agency (NOTE: Nationality of each partner, Majority Shareholder, Director and Chairman of the Agency be indicated) 8 ... Name and exteht of Facilities available
9. Qualification of staff engaged for imparting instruction:
Name:·······································••.•························· Age: ..................... _ .... ' ............................................. .
Designation : ........................................ -.. · ............ :." ..
-
10. Particulars of the uniform including colour, in case the applicant intends to use any uniform for' the private domestic work and supervisors of the Agency.
11. Does the applicant intend to operate in more than one district? If so, please mention name of the districts -
1. . ..... ········ ....................................... .
2. ·············· ........................................ .
3 . ..................................................... .
4. ·········-- .. ············· .. ,·.············· ......... .
5 . ...................................................... .
-924 (33) 924 (34) ~_§~·il,t·i'lit~. ~ 21 Wffi'f 2014
12. Does the applicant intend to operate in the entire state? (Yes, ~,u,
13. Does the applicant possess the training facility on its own or will ' ' get it on outsourcing basis? The details o( training facility should be furnished (as annexure) Enclosure : ..:
t• Address of applicant Telephone number of the applicant Date of application r. Copy of current Income Tax Clearance Certificate
2. Affidavit as prescribed in sub-section(2) of ~e,ction 7 the Act
3. Other enclosures - Form-II (S~e ~e 4) , Form for verification of Antecedents *Thumb Impression* of the Applicant ______ _ Signature of the Applicant-----,-------- For official use only .
Form Number Name of· the police station, sent for police verification ,.
Fee Amount Rs. ______ Cash/D.D. ____ _ Name of Bank & Branch ------------- D. D. No. __________ Date of Issue ____ _ Recent Passport Size Photograph Attested By A Class-I Gazetted Officer Date N.fL : Please_read the instructions carefully before filling the form. Please fill in BLOCK LLTTERS:
(Note: Please furnish correct information. Furnishing of incorrect information or suppression of afij,' material information m the form will render the candidate unsuitable for grant o{ license) ~
1. Name of applicant (Initials not allowed) First Name Middle Name Last Name ------ ------
2. If you have ever changed your name, please indicate the previous nfu.'!!~ in full ·--'--~-------------------------
3. Sex (male/female) ______ _
4. Qsite of Birth ______ _
5. Place of Birth: Village/Town ________ _ District. ________ ~ State &'Country_~--------
6. Father's full name/Legal Guardian's Full Name (including surname, if any):(lnitials not allowed) __________________ _
7. Mother's full name (including surname, if any):(Initials not allowed} _____________________ _ 8 .. If Married. Full nruile of spouse (including surname, if any):(Initials not allowed) ____________________ _ 924 (35)' ,-
9.24 (36)
9. Present Residential Address including Street No./Police Station, vmage and District (with PIN code), ___________________________ _ Telephone No./Mobile No. __________ Off.
Res. Fax _______ Email ID __________________ _
10. Please give the date from which applicant residing at the abovementioned address: DD/MM/YY ___ _
11. Permanent Address including · Street No./ Police Station, Village and District (with PIN code) ______________ _
12. If you have not resided at the address given at column (9) continuously for the last ·five years, please furnish the other address (addresses) with duration (s) resided. You should furnish additional photocopies of this form for each additional place of stay during the last five years. Forms may be photocopied; but photograph and signature· in original are required on each form.
Address Ftotn
13. In Ct:t!3~ 0f stay abrQad, particulars ·of all places where you have reside_d for·more than one year after attaining the age of twenty-one years.
14.
a) b) Other Details:
Educational Q:u~fications: · Previous: positions ,held, if any, ,along with- name and address of employer( s).
·c) Reason for leaving:last employment:"':· _____________ _ , d) Visible Disfingui_shihg ~ark:
. .'".r .·•. •.
,"'1 j e)• Have you-ever been dismissed/ ·removed from Government- sei account of misconduct or moral turpitude?
15. Did you ·earlier operated any Private Placement Agency or were its partner, majority share holder, or. Director? If yes, then furnish the name, address of the agency and its license particulars.
16. Are you a citiz.en of India by: (Birth/Descent/Registration/ Naturalisation? If you have ever possessed any other citizenship, please indicate (the same). ·
17. Have you, at any time, been convicted . by a court in India for any offence and sentenced to imprisonment? If so, give name of the court, case number, and offe1;1ce.(Attach copy judgment)
18. (a) Are any criminal proceedings p•!nding against you before a court in India? If so, give name of court, ca,e n~mber, and offence , (b) Have you been keeping links with any organ~tion or association· which is banned under any law on account of their activities which pose threat to national security or public order?•.
19. Self- Declaration:
Date:
Place:
The information given by me in this form and the enclosures is true ~ correct and I am solely responsible for its accuracy.
(Signature /Thumb Impression.* of applicant) --------- 924 (37) 924 (38) ~.fo·fltlll~ffiJT.BI, ~ 21 ~ 2014 , .... .,
20. Enclosures:
. ,.
(Signature/Thumb Impression *of applicant) (*Left Hand Thumb Impression if Male and Right Hand thumb Impression if Female) FOR OFFICE USE ONLY :
File No. ---~--------- Date of issue of C&A report ______ _ - (Signature of Police Station In-charge) Name of Police Station --------- Name of Police District _______ _ Note:-
(i) Three passport-size photographs duly attested by G.O. on reverse of photograph in respect of applicants.
(ii) Proof of Age
(iii) Certificate of fncorporation issued by ROC, Sale Tax No. (ST-2), Labour Licerise, Regfstration urider ESI1 Act &,EPF Act, 1952
(iv) ~i.te Plan of ~office
(v) Proof of resic~ence, of Applicants ~ ,. . • • • . >' • )
(vi)_.. P.re_scriped. F~(,:!:S . . ' . . '\_\ .. ' ~ . . .
. J . . . . . .
· (vii) NOC from landlord for carryin[ on trade of Placement Agency Business_ at the premises.
·•· ·-·· .'4 Form-III (See rule 5) Form for verification of Character & Antecedents of Domestic Worker Thumb Impression of the Applicant··················~···························'······· Signature of the Applicant .................................................................. .
For official use only Form number Name of the police s~tion sent Date for police verification I Fee Amount Rs ........................................ Cash/D.D .................................. .
Name of Bank & Branch ....................................................................... .
D.D. No ............................................... Date of Issue .............. : ..... ............. .
N .8. Please read the instruction carefully before filling the form.
Please fUlin BLOCK LETTERS.
(Note: Please furnish correct information. Furnishing of . incorrect information or suppression of any material information in the form will render the candidate unsuitable for employment/ engagement m private agencies.)
1. Name of application (Initials not allowed) First Name ....................... Middle Name ....................... Last Name .............. .
2. If you have ever changed your name, please indicate the· previous name
(s) in full .................................................................................................. .
3. Sex (male/female) ................................. .
4. Date of Birth ...................... .
5. Place of Birth: Village/ Town ............................................. Distt .. _. ......... .
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 of spouse (including surname if any):(Initials not allowed) ....................... · ............... ••••••.••••••••••·•···.,·············.-············· .. ············:/
9. Present Residential Address including Street No./Folice Station, Village and District (with PIN code) ...................................................................... .
♦ ♦ ♦ o ♦ o ♦ ♦ o ♦ o ♦ ♦ ♦ o o • o • o ♦ • • • • • • • • • • • • • • • • • • 4 0 e e • e • • -o • • • • • • • • • • • • • 0 • • • e • • • • • • ♦ • e o • • o • • • • ~ • • • • ♦ • • • ♦ • e • • e • • • -0 • • e • • • • e • • • • • I Telephone No./Mobile No ........................ : ............................................. .
~ 924 (39) 924 (40) Off . ...... ·:-:.:: .. '. ... : ............ ... Res ......................................... Fax ..................... .
Email ID .............................................................................................. ..
~O. Please give the date from which applicant is residing at abovementioned address: DD/MM/YY ........ / ........ / ........... ..
11. Permanent Address including Street No./ police Station, Village and District (with PIN code) ................................................................................ .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. If you have not resided at the address given at column (9) continuously for the last five year, please furnish the other address with duration (s) resided. You should furnish additional photocopies of this form for each additional place of stay during the last five years. Forms may be photocopied, but photograph and signature in original are required on each from.
Address From To .............................. !••············· .. ············· .............................................................. .
-················ ...................................................................................................... .
13. In case of abroad stay, particulars of all places where you have resided for more than one year after attaining the age of twenty-one years.
\.
..... ~ ............................. ~ ....................... • ........................... ., .............................. .
14. Other Dctailo:
(a) Educational Qualifications: .............................................................. .
(b) Previous posts held along with name and address of employer (s) .... ..
(c) Reason (s) for leaving last employment:· .......................................... ..
(d) Have you ever been dismissed/removed from Government service on account of misconduct or moral turpitude? (Yes/No)
(e) Visible Distinguishing Mark: ............................................ '. ............ ,
(f) Height (ems) ............................................................................. .
15. Are you working in Central Government/State Government/Public Sector Undertakings/Statutory Bodies (Yes/No) ,.
924 (41) ~-
16. Are you citizen of India by: (Birth/Descent/ Registration/Naturalisation) If you have ever possessed any other citizenship. Please indicate previous . . h. ? citizens 1p .................... . : ..... ................................................................ .
17. (a) Have you, at any time, been convicted by a court in India for any ,.,, offence & sentenced to imprisonment? If so, give name of the c~mrt, case number and offence. (Attach copy of judgment) ........................................... -........................................................................... .
(b) Are any criminal proceeding pending against you before a count in India? If so, give name of court, case number, and offence .................................................................................................................................................................................................... _ ......... .
(c) Did any court issued a warrant or summons for appearance. (as an accused) or warrant for arrest or an order prohibiting your departure from India? so, / give name, case number and offence ................................. ······.·········· ... ······················································· ............................... la ...... i, .......................... ~ ............... lo ..... l, .................................... j • (d} Are you associated with any organizations or associati9_11· which is.
banned under any law on account of their activi~t~s which posts threat to national seclirify ot ptiblic order?
18. Self - Declaration:
The inforrtm._\i~~ ~\'(JP. py i;µe i.fl t\l\& form qnd. enc~osures is true & correct mt4 l ~ ~<;>,l~\y re&pP:n.&ipl~ f Pf it~ ~fcurqcy.
(Signature/T.I.* of applicant) (-1<. Left Hang TtH-lffiP. lmpression if Male and Right Hand thumb Impression if Female) Date: ··r.-··•"•·•···..'""·•·· .,, Place: . .,, .. ,., ..... , ........ ;
19. Particula.:rs of person to be in the event of death or accident:
Name: ..... , ......... , ......................... .
Address: ......... <t.••····················•e,••················································ , Mobile/Tel.No ......................................... ..
20. Enclosures: ......................... .
(Signat:ure/T.I. * of applicant) 924 (42) ~.fofl-HJ I~ {FifT.r,l, ~ 21 3Pffi'r 201 4 FOR OFFICE USE ONLY •File No.· ... -.. ;·· ...... .- ... , .. · ............. :·: . .' .......... :· ..... .
Date of issue of C&A report ....................... .
(Signature of Police Station In-charge) Name of Police Station ............................... .
Name of Police District ........... ......... : .......... .
Note:-·
(i) Three passport-size photographs
(ii) Proof of age (Birth certificate, School leaving Certificate, Matri.cul~tion Certificate )
(iii) Proof of residence
(iv)Training certificate • ~liillH•I~ ~. ~ 21 ~ 2014 Form-IV (See rule 5) CHARACTER & ANTECEDENT CERTIFICATE This is to certify that' Mr./Ms ............ , ............................................. 8/o D/o Shn. R/ ···········•······· .....•..•... ; .. _.......................... 0 ····••.•································· whose particulars are .given below, has goo.d moral character and reputati~n and that the applicant has been staying at the · following address continuously for the last one year.
Date of Birth : ··••.•················································································· Place of Birth : ........................................................................................
Educational Qualification: ..... · .................................................................... .
Profession: .......................................... -.............. ~ ................... ~ ....... , .. .
Present Address:
Permanent Address:
Issuing Authority :
Date of Issue ................................................................ ;. ............................................. .
Signature: .................... ; ...... .
Name · Designation Address/Tel.No.
924 (43) ··-~·-· 924 (44) _/ .- Form-V (See rule 6) ' .
_LICENCE.TO ENGAGE IN BUSINESS OF PRIVATE PLACEMENT AGENCY Serial No ........................................................................................................ .
Date .............................. : .......................................................... ; .................. .
Shri/Smt./Ku ......................................................... (Name of.The Applicant) S/o W /o D/0 ................................... : ......................................................... .
R/o ....................................................................................... (full address) i's granted the_ license by the Controlling Authority for the State of .
........................................................ to run the business of private ' Placement agency in the district(s) of/State of (cancel the inapplicable words) .................... -...................................................... _ ................................ .
....................................... ....................................................... with office at .............. ,., ................................... : ................................ (address of the office) Place of Issue ............................................. .
Date of Issue ............................................... .
This license is valid upto ................................. .
. Signature Name of Granting Authority Designation Official Address This licen~ is renewed upto .. ,, ................. · ......... ,, ..
Date of renewal Signature Name of Renewal Authority Designation Official addre&.s Form-VI (See rule 11) FORM FOR APPEAL .I An appeal under Rule 11 of the Chhattisgarh Private Placement Agencies (Regulation) Rules, 2014 against the order of the Controlling Authority Appellant _______ _ S/o W /o D/o ____ ,_: __ Age _________ _ R/o _________ _ Above appeal is presented to the Principal Secretary/Secretary (Home} against the order dated _____ of the Controlling Authority refusing to grant/ renew license to run Private Placement Agency· on the following grounds, namely:-
1. -----------
2.
3. -----------
4. ----------- Enclosed list of documents Dme Place Signature Name, Designation & Address of the Appellant 924 (4S) 924 (46) S.No.
1 S.No ·1 S.No.
S.No.
+ Name of Person(s) managing the agency Form: VII (See rule 12) REGISTER OF PARTICULARS (Part-I Management details)· Parent's/ Present Permanent Nationality Father's address address Name & phone no Date of joining/ leaving the agency (Part-II Private Security Guards and Supervisor) Name Father's Present Date of Permanent photo Badge Salary of Name Address joining/ Address graph no. with guard/ & leaving date superv- phone the isor no. agency (Part-III Customers) Name of Address Number Date of Date of the of the and ranks commencement discontinuation Customer place of of Services of services & phone where domestic no. domestic worker work is provided provided (Part-IV Duty ·Roster) Name of Address Whether Date and time Date and time the of the provided of of ending of duty private place of with any commencement domestic duty arms/ of duty worker/ ammunition supervisor I -~ Name Name u«f~•lq(NfQSI, ~ 21 ~2014 Form.-VID (See rule 13) 924 (47) PHOTO-IDENTITY CARD FOR PRIVATE DOMESTIC WORKER/SUPERVISOR of of the the Private Placem,ent Agency Private Domestic Worker/Supervisor Photograph Of The Holder Duly Attested By The Issuing Authori . _ Official Designation ..,._ ---------------------'-----'------ Identification no: of the domestic worker/ Supervisor ________ _ Date of Issue------,---~---'----- Valid upto --------'------ Signature of the cardholder __________ _ Signature of the issuing Authority Official Designation __ _