Declaration:
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) Date:
Place:______________
19. 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 Incorporation issued by ROC, Sale Tax No. (ST-2), Labour Licence, Registration under ESI Act & EPF Act
(iv) Site Plan of office
(v) Proof of residence of Applicants
(vi) Prescribed Fees
(vii) NOC from land-owning agency for carrying on trade of security agency business at the premises Form II (See rule 5) Passport size recent photo graph attested by a *(Note) Form for verification of Character & Antecedents of Guard / Supervisor Thumb Impression* of the Applicant__________________ Signature of the Applicant ___________________________ For official use only Form number Name of the police station sent for police verification Date Fee Amount Rs.________________ Cash/D.D._____________ Name of Bank & Branch____________________________________________ D.D.No._________________________ Date of Issue ____________________ N.B.: Please read the instructions carefully before filling the form. Please fill in BLOCK LETTERS: (CAUTION: 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 in private agencies.)
1. Name of applicant as should appear in the photo-identity card (Initials not allowed) Last Name______________ Middle Name _____________ First Name ______________
2. If you have ever changed your name, please indicate the previous name(s) in full _________________________________________________________________
3. (a) Sex (male/female) ____________ (b) Date of Birth _____________________
4. Place of Birth: Village/Town _______________________ Distt.______________ State & Country ____________________________________________________
5. Father’s full name /Legal Guardian’s Full Name (including surname, if any):(Initials not allowed) ___________________________________________________________________________________
6. Mother’s full name (including surname, if any):(Initials not allowed) _____________________________________________________________________________
7. If married. Full name of spouse (including surname, if any), :( Initials not allowed) ____________________________________________________________________
8. Present Residential Address including Street No./Police Station, Village and District (with PIN code) ___________________________________________________________________________________ ___________________________________________________________________________________ Telephone No./ Mobile No.______________________ Off. __________________ Res. ________________ Fax ______________________ Email ID___________________________________________________
9. Please give the date since residing at the above-mentioned address: DD/MM/YY _______________________
10. Permanent Address including Street No./Police Station, Village and District ( with PIN code) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
11. If you have not resided at the address given at COLOUMN (9) continuously for the last five year, 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 from.
Address From To ________________________________________________ _________________ _____________ ________________________________________________ _________________ ______________ ________________________________________________ _________________ _____________ ________________________________________________ _________________ _____________
12. In case of stay abroad, particulars of all places where you have resided for more than one year after attaining the age of twenty-one years.
___________________________________________________________________________________ ___________________________________________________________________________________ _____________________________________________________________________
13. Other Details:
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 Govt. service on account of misconduct or moral turpitude? (Yes/No) e. Visible Distinguishing Mark:____________________________________ f. Heights (Cms) ______________
14. Are you working in Central Govt./State Govt./PSU/Statutory Bodies ( Yes / No )
15. Are you a citizen of India by: (Birth / Descent / Registration / Naturalisation). If you have ever possessed any other citizenship, please indicate previous citizenship?
___________________________________________________________________________________
16. Have you ever been involved in criminal case in India, if yes whether the case is pending investigation/pending trial, resulted in conviction / acquitted / discharge / compounding etc (give status/details and add copy of judgement if any).
___________________________________________________________________________________
17. (a) Have you ever been arrested, deported or involved in any illegal act in any other country where you have visited or resided.
_____________________________________________________________________ _____________________________________________________________________
(b) Have you been keeping links with any organization or association which is banned under any law on account of their activities which pose threat to national security or public order?
18. (i) Do you hold a valid arms license ?
(ii) If yes, the details thereof.
* Arms License No.
* Date of issue * Area Validity * Valid upto * Weapon(s) held on the arm license Type No.
-------------------------------------------------------- -------------------------------------------------------- *Last renewed from ------------------------------- *Whether Arm License has been registered in Delhi?
If yes, date of registration
19. Attach proof of identity and residence, viz. passport, PAN card, driving license, ration card etc.
20. Unique Identification Number (Adhar), if acquired: