Declaration:
The information given by me in this form and enclosures is true & correct and I am solely responsible for its accuracy.
(Signature/T.I.* of applicant) (*Left Hand Thumb Impression if Male and Right Hand thumb Impression if Female) Date:______________ Place:______________
22. Particulars of person to be intimated in the event of death or accident:
Name ___________________________________________________ Address:_________________________________________________ __________________________________________________ Mobile/Tel.No.____________________________________________
23. Enclosures: ____________________________________________________ ______________________________________________________________ ______________________________________________________________ (Signature/T.I. of applicant) 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:- (The photographs can be attested by a Gazetted Officer or by elected representatives of people {like Sarpanch, MLA and MP).
(i) Three passport-size photographs
(ii) Proof of age (Birth certificate, School leaving Certificate, Matriculation Certificate)
(iii) Proof of residence
(iv) Training certificate FORM – III (See rule 5) CHARACTER & ANTECEDENT CERTIFICATE This is to certify that Mr./Ms.____________________________________, S/o / D/o Shri ______________________________R/o_____________________________________________ _____________________________, whose particulars are given below, has good moral character and reputation 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 Signature Name Designation Address/Tel. No.
Date of Issue Form IV (see rule 6) Training Certificate Serial number Name of the Training Agency Address of the Training agency License No.
Certified that ____________________________________ son/daughter of _________________________________ resident of _________________________ ______________________________________________________________________ has completed prescribed training for the engagement or employment as a Private Security Guard from ____________ till _____________.
His signature is attested below Signature of the Certificate Holder Signature of issuing authority Designation Place of issue Date of issue Form V (See rule 3) APPLICATION FOR NEW LICENCE/RENEWAL OF LICNECE TO ENGAGE IN THE BUSINESS OF PRIVATE SECURITY AGENCY To The Controlling Authority _______________________ _______________________ The undersigned hereby applies for obtaining a licence to run the business of operating services in the area of Private Security Agencies;
1. Full name of the applicant
2. Nationality of the applicant
3. Son/Wife/Daughter of
4. Residential Address
5. Address, where the applicant desires to start his Agency
6. Name of the Private Security Agency (NOTE: Registration Number of the Agency also be indicated)
7. Name and Address of Proprietor, Partner, Majority shareholder, Director and Chairman of the Agency.
(NOTE: Nationality of each Partner, Majority Shareholder, Director and Chairman of the Agency be indicated)
8. Name and extent of facilities available
9. Qualification of staff engaged for imparting instructions:
Name _____________________________ Age _______________ Designation _______________________
10. Equipments which will be used for security services.
DFMD HHMD Mine Detector Other Detectors Wireless Telephones Alarm Devices Armored Vehicles Arms Armory NOTE : Strike off the equipment(s) not to be used for security services.
11. Particulars of the uniform including colour in case the applicant intends to use any uniform for the private security guards and supervisors of the Agency.
12. Does the applicant intend to operate in more than one district? If so, please mention name of the districts - 1____________ 2____________ 3____________ 4____________ 5____________
13. Does the applicant intend to operate in the entire state? (Yes/No)
14. Does the applicant possess the training facility on its own or will get it on outsourcing basis? The details of training facility should be furnished. (as annexure) Signature Name of the applicant Address of the applicant Telephone number of the applicant Date of application Enclosure:-
1. Copy of current income tax clearance certificate
2. Affidavit as prescribed as in Section 7 sub-section (2) of the Act
3. Other enclosures Form VI (See rule 9) Licence to engage in the business of Private Security Agency Serial No.________________________ Date ____________________________ Shri _________________________________________________(name of the applicant) s/o_____________________________________________________________________ r/o_____________________________________________________________________ ____________________________ (full address) is granted the license by the Controlling Authority for the State of _____________________________ to run the business of private security 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 licence is valid up to _____________________ Signature Name of granting authority Designation Official address This licence is renewed up to ______________________ Signature Name of renewing authority Designation Official Address Date of renewal Form VII (See rule 14) Form for Appeal An appeal under rule 14 of the Rules against the order of Controlling Authority Appellant ________________________________________ s/o ______________________________ r/o________________________________ Above appeal to the Principal Secretary /Secretary (Home), against the order of Controlling Authority dated _________________ and against refusal of licence to run private security agency, namely _______________________ and sets forth the following grounds of appeal, namely
1. _____________________________
2. _____________________________
3. _____________________________
4. _____________________________ Enclosed list of documents Signature Name, Designation & Address of the Appellant Date Place Form VIII (See rule 15) Register of Particulars (Part –I Management details) S.No. Name of persons(s) managing the agency Parent’s/Father’s Name Present address& phone no Permanent address Nationality Date of joining /leaving the agency
1.
(Part –II Private Security Guards and Supervisor) S.No. Name of guard/supervisor Father’s Name Present Address & phone no.
Date of joining/ leaving the agency Permanent Address Photograph Badge no.
Salary with date
1.
2.
(Part –III Customers) S.No. Name of the Customer& phone no.
Address of the place where security is provided Number and ranks of security guards provided Date of commencement of Services Date of discontinuation of services (Part IV Duty Roster) S.No. Name of the private security guard/ supervisor Address of the place of duty Whether provided with any arms/ ammunition Date and time of commencement of duty Date and time of ending of duty Photograph of the holder duly attested by the issuing authority Form IX (See rule 16) Photo-Identity card for Private Security Guard/Supervisor Name of the Private Security Agency ______________________________________ Name of the Private Security Guard /Supervisor______________________________ Official Designation ___________________________________________________ Identification no. of the Guard/Supervisor __________________________________ Date of Issue__________________________ Valid up to ________________________ Signature of the cardholder _______________________ Signature of the issuing authority Official seal