Proforma for Police Verification
1. Name of post _____________________________________________________
2. Name in full (in block Surname Name
capitals)with aliases if any
Please indicate any part of
your name of surname.
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3. Present Address in full (i.e. Village, Tehsil
Thana and Distt. or House No./Lane/Street
and Road.
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4. a) Home/Permanent address in full ((i.e. Village, (a)
Tehsil Thana and Distt. or House No./Lane/Street
and Road.
b) Place of birth, Distt. and State in (b)
which it is situated.
c) District and State of which you belong. (c)
d) District and State in which property is held. (d)
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5. Particular of place where you have resided
for more than one year, during proceeding
five years.
From_____________________ To _____________________Residential address in full i.e. Village,
Tehsil Thana and District/H.No./Street
and Road.
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6. a) Fathers Name in Full(with alias if any)
b) Present postal address (if dead, give last
address).
c) Permanent Home Address
d) Profession
e) If any service, give designation and official
address.
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7. a) Exact date of birth as given in a)
the Matriculation Certificate.
b) Present Age. b)
a) Height c)
b) Age at the time of passing Matric. d)
c) Marks of identification. e)
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8. a) Are you a member of Schedules Caste or a)
Schedules Tribes/Backward Classes of Haryana
If so , State the name there of.
b) If member of Schedules Caste, State your religion/ b)
Caste. If a member of Backward class, State your State.
9. Educational qualifications showing place of education with years in school and college since 15th years
of age.
Name of the School /College Date of entering Date of examination
With full address on leaving passed
10. Details of previous employment :-
Designation of post Period Full address of Detailed reasons
Held or description. office/ firm and for previous service
Institution.
11. Are you an Ex- Eco, ESSC or Ex-Servicemen or likely to be released ? if so, state the (i) rank (ii)
officer (iii) Jr. Commissioner/ officer and;
12. Have you ever been convicted by court
of any offence? If so , full particulars
of the convications and the sentences
should be given.
13. Name of the two responsible persons of your locality or two reference to whom you are known with
their full address.
i)
ii)
14. Are you married ? If yes, name and address of spouse.
15. I certify that the foregoing 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 employment under
the Government.
Signature of the Candidate
Date____________________
Place____________________
Certificates to be signed by a Gazette officer or a member of Legislature or other authority
prescribed by the appointing authority.
Countersign by Institute Incharge
Certified that I have known Sh. /Smt./Km.____________________________________
Son/daughter/wife of Sh. ____________________________________for the
1st__________________years_________months and that to the best of my knowledge and belief the
particulars furnished by him/ her are correct.
Signature, Name and designation
of status and address
Remarks of the verifying officer ___________________________________
___________________________________
Signature
Name and Designation of verifying officer
