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Form II

This document contains a form for verification of character and antecedents for housekeeping staff and supervisors. The 3-page form requests information such as the applicant's name, date of birth, permanent and present addresses, educational qualifications, employment history, citizenship status, and criminal history. It must be signed and include a recent passport photo of the applicant for identification purposes.

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kalyan
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93 views5 pages

Form II

This document contains a form for verification of character and antecedents for housekeeping staff and supervisors. The 3-page form requests information such as the applicant's name, date of birth, permanent and present addresses, educational qualifications, employment history, citizenship status, and criminal history. It must be signed and include a recent passport photo of the applicant for identification purposes.

Uploaded by

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

(See Rule 4)

Form for verification of Character and Antecedents of House Keeping Staff and Supervisor.

Thumb impression* of the Applicant Passport Size


recent
photograph
attested by
Signature of the Applicant Gazetted
Officer

For official use only

Form Number Name of the police station to which sent for Date
police verification

Fee Amount Rs. Cash/ D.D.

Name of Bank D.D. No.

Date of Issue

Please read the instructions carefully before filling the form. Please fill in BLOCK LETTERS:
(CAUTION: Please furnish correct information. Furnishing of incorrect information or
suppression of any factual information in the Form will render the candidate unsuitable for
employment/engagement in the Private Agency.

1. Name of the applicant as should appear in the photo-identity card (initials not
allowed)

Last Name First Name

2. If you have ever changed your name, please indicate the previous name(s) in full .

3. Sex (male/female)
4. Date of Birth

5. Place of Birth: Village/Town

District, State & Country

6. Father’s Full Name/Legal Guardian’s Full Name (including surname, if any); (initials not
allowed)

7. Mother’s Full Name (including surname, if any): (initials not allowed)

8. If married, Full Name of Spouse (including surname, if any) (initials not allowed)

9. Present Residential Address, including Street No./Police Station, village and District
(with PIN Code)

Telephone No./Mobile No.

10. Please give the date since residing at the above-mentioned address: DD
MM YY

11. Permanent Address including Street No./Police Station, village and District (with PIN
Code)
12. If you have not resided at the address given at COLUMN (9) continuously for the last
five years please furnish the other address (addresses) with duration (s) resided. You
should furnish additional photocopies of this Form for each additional place of stay
during the last five years. Forms may be photocopied, but photograph and signature in
original are required on each Form.

From …………….. To ……………. From ……………… To …………………

13. In case of stay abroad particulars of all places where you have resided for more than
one year after attaining the age of twenty-one years.

14. Other Details :

(a) Educational Qualifications:

(b) Previous positions held, if any, along with name and address of employer:

(c) Reasons for leaving last employment :

(d) Visible Distinguishing Mark :

(e) Height (cms)

15. Are you working in Central Government/State Govt/ PSU/ Statutory Bodies. Yes/ No.

16. Are you a citizen of India by: Birth/Descent/Registration/Naturalization:


If you have ever possessed any other citizenship, please indicate previous citizenship
17. Have you at any time been convicted by a court in India for any criminal offence and
sentenced to imprisonment ? If so, give name of the court, case number and offence.
(Attach copy of judgment)

18. Are any criminal proceedings pending against you before a court in India? if so, give
name of court, case number and offence.

19. Has any court issued a warrant or summons for appearance or warrant for arrest or an
order prohibiting your departure from India ? If so, give name of court, case number and
offence .

20. Self – Declaration:


The information given by me in this form and enclosures is true and I am solely
responsible for accuracy.

(Signature/T.I* of applicant)

(*Left Hand Thumb Impression if Male and Right Hand Thumb impression if Female) Date

………………

Place ……………..

21. Particulars of person to be intimated in the event of death or accident : Name

Address

Mobile/Tel. No.

22. Enclosures :
(Signature/T.I* of applicant)

(*Left Hand Thumb Impression if Male and Right Hand Thumb impression if Female)

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

* N.B. Cancel entries not applicable.

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