CHARACTER AND ANTECEDENTS VERIFICATION FORM Photo
CHARACTER AND ANTECEDENTS VERIFICATION FORM
Photo
Sr.
Particulars
No.
1. Full name with aliases, if
:
any
(Please indicate if you
have added or dropped at
any stage any part of
name or surname)
2. Present address in full, :
with police station and
district.
3. Home/ Permanent address :
in full with police station
and district.
4. Particulars of place with periods of residence where you have resided during
the preceding two years
Period
From
5.
6.
Address in full with P.S and Distt.
To
Father¡¯s name in full with aliases , if any
Nationality:
Place of
Occupation.
Birth
(If employed give
designation
and
office address)
Permanent Address
Applicant ¡®s Nationality
:
Present Address
7.
Date of Birth:
Age at Matriculation:
8.
Two
marks
of :
identification
9.
Educational Qualification showing places of education with yrs in school &
colleges since 15 yrs of age.
Name
of
School
Period
Examination Passed
/Colleges
with
full
From
To
address
HighSchool/SSC/Matric
Intermediate
Graduate
Post Graduate
10 Give full particulars with details of previous & present employments up-to
¨Cdate:
Period
Designation Full name &address
Nature of Reason for
of
employment leaving
employer/organization
previous
services
11.
If the previous employment was under the
Govt. of India / State Govt.
Undertaking owned of controlled by Govt./ or
autonomous body/
University / local body, state briefly whether
you had been terminated/
Removed /dismissed from service on any
disciplinary proceedings/
Charges or had you been called upon to
explain your conduct in any matter before or at
a subsequent date of your actual termination/
Dismissal/removal retirement, etc.
12.a Have you ever been arrested?
Yes
No
b. Have you ever been prosecuted?
Yes
No
c. Have you ever been kept under detention?
Yes
No
d.
Have you ever been bound down?
Yes
No
e.
Have you ever been fined by a court of law?
Yes
No
f.
g.
h.
13.
Have you ever been convicted by a court of
Yes
law?
Is any case pending against you in any court of
Yes
law?
Whether discharged/expelled withdrawn from
Yes
any training institution under the govt. or
otherwise?
Names & address of two responsible persons 1.
other than relatives to whom you are known.
2.
No.
No
No
I certify that the following information is correct and complete to the best
of my knowledge and belief. I am not aware of any circumstances, which might
impair my fitness for issue of PIC for airport entry.
Counter signature of
Employer/ authorized
Signatory with stamp
Signature of applicant
Date________________
Place________________
................
................
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