Certified that I met/was visited by police authorities in order to carry out my/my dependent minor child’s verification on date: ____ ____ ______ ______ ___ ___ at time: _________ _________ ____ ____ Note for Applicant: The Police Verification Process is deemed to be completed only after receipt of the Police Verification Report at the Passport Office.
Signature/Left thumb impression of applicant (or authorized signatory in case of minors/other applicants who cannot sign)
Part A 1. Is the photograph given in the PP Form same as that of the applicant?
Yes
No
2. Are the applicant’s name and personal particulars same as that mentioned in the PP Form?
Yes
No
3. Has the applicant been living (except for visits outside) at the address and duration of stay as mentioned in the PP form, subject to stay of maximum one year?
Yes
No
4. Are you satisfied that the applicant is a citizen of India?
Yes
No
For Questions 1 to 4 above, if any of the answer is NO, provide required details in the box given below:
5. Has the applicant, during the past five years been convicted and sentenced to imprisonment of two years or more? 6. Is there any "Court Order" from any Court against the applicant’s departure overseas?
Yes
No
Yes
No
7. Are any Proceedings against the applicant pending in any Criminal Court?
Yes
No
8. Are there any pending “Warrants of Arrest” or “Warrants/Summons for Appearance” against the applicant? 9. Has the applicant travelled abroad?
Yes
No
Yes
No
Yes
No
Yes
No
For Questions 5 to 9 above, if any of the answer is YES, provide required details in the box given below. If answer to Question 5, 6, 7 and/or 8 is YES, specify the case number and relevant details of the case.
10. Is the applicant an employee of the Central or State Government/ the Armed Forces/Statutory Body /Public Sector Undertaking? Undertaking? If Yes, please specify the name of organization: _____________________________________ 11. Do you have any information regarding the applicant holding any passport? If Yes, please provide the Passport No.: __________________, Date of Issue: _________________, Place of issue: ________________________________________________________________. ID and Name of Investigating Officers
Date of Investigation
Signature
Part B 12. Has the applicant indulged, or likely to indulge in any activity which could be prejudicial to the sovereignty and integrity of India, the security of India, friendly relations of India with any foreign country, or the interests of the general public? If Yes, attach additional sheet with required details.
Yes
No
BASED ON THE ABOVE, ISSUE OF PASSPORT TO THE APPLICANT IS: Reco Recomm mmen ende ded d (Cl (Clea earr PVR PVR)) Not Not Rec Recom omme mend nded ed (Adv (Adver erse se PVR) PVR)
Date:_______________________
For Sr. Superintendent of Police Name of the Officer with Seal
