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Application Form For Police Clearance Certificate (PCC)

This document contains an application form for an Indian Police Clearance Certificate (PCC). The form requests information such as the applicant's name, nationality, passport details, addresses in India and the Netherlands, purpose of travel, and whether the applicant has any criminal convictions. It states that knowingly providing false information on the form is an offense. The applicant must provide details of residence in India, dates of travel, employment, education or other purposes for requesting the PCC to be considered for the certificate.

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amitsin01011994
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216 views2 pages

Application Form For Police Clearance Certificate (PCC)

This document contains an application form for an Indian Police Clearance Certificate (PCC). The form requests information such as the applicant's name, nationality, passport details, addresses in India and the Netherlands, purpose of travel, and whether the applicant has any criminal convictions. It states that knowingly providing false information on the form is an offense. The applicant must provide details of residence in India, dates of travel, employment, education or other purposes for requesting the PCC to be considered for the certificate.

Uploaded by

amitsin01011994
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Embassy of India,

Buitenrustweg 2,
2517 KD, The Hague,
The Netherlands.
Tel No.0031-703469771
FaxNo.0031-703562523
E-mail: [email protected]

APPLICATION FORM FOR POLICE CLEARANCE CERTIFICATE (PCC)


Affix recent
passport size
1. Name (block letters) Mr./Mrs./Miss. __________________________________________
photo

2. Marital Status: __________________________________________________________

3. Father’s name and nationality_______________________________________________

4. Profession of the applicant__________________________________________________

5. If married, please state:(a) Maiden name if any, ________________________________

(b) Spouse’s name ____________________(c) Nationality of the Spouse_____________

6. (a) Nationality of the applicant ______________________________________________

(b) Country, Place and Date of Birth __________________________________________


7. Passport Particulars of the Applicant:
Passport No.: _____________________ Place of Issue: ____________________
Date of Issue: _____________________ Date of Expiry: ____________________
8. (i) Pervious nationality (if you have changed your nationality) _____________________
(ii) Particulars of previous passport:
Passport No.: _____________________ Place of Issue: _____________________
Date of Issue: _____________________ Date of Expiry: _____________________
9. Have you been to India since you changed your nationality? (Please furnish details, if Yes)

10. Address in India: __________________________________________________________


_______________________________________________________________________
11. Address in the Netherlands: _________________________________________________
___________________________________________________POST CODE____________
12. Contact Telephone No.
Mobile no.: _____________ Residence: ______________ Business: __________________
E-mail Address: __________________________________________________________
13. Have you ever been convicted by any court in India or abroad? YES/NO
14. Is there any Police case pending against you in India or abroad? YES/NO
15. Have you received any financial help from the government of India/State Government
or any other institute or organization in India in connection with your visit to the
Netherlands? If Yes, please furnish details.

16. Have you ever served under the Central/State Government of India? If Yes, have you
resigned from your service? (please attach copy of acceptance letter)
17. FOR NON-INDIAN APPLICANTS:
Place of residence (with full postal addresses) whilst in India, with dates
SI. No. Address where stayed From To

18. Purpose of this application (Delete whichever not applicable):


(i) Wishing to proceed to ______________________________________(country)
(ii) For study in (subject) ________________________________________
(iii) For permanent settlement as an immigrant YES/NO (please strike off which is not applicable)
(iv) For seeking employment YES/NO (please strike off which is not applicable)
(v) For any other purpose (state the details)________________________________

I solemnly declare that the information given above is correct and nothing has been concealed
and I am aware that it is an offence to knowingly furnish false information or suppress material
information.

Place: The Hague Signature of the Applicant

Date:___________ Name ___________________

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