Form – I

(See rule 3)

FORM FOR VERIFICATION OF ANTECEDENTS OF APPLICANT

Thumb Impression * of the Applicant:

Signature of the Applicant :

For official use only

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

Fee Amount Rs.----------- Cash/D.D-------------

Name of Bank---------- D.D No. --------------

Date of issue--------------

Please read the instruction 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 grant of license)

1. Name of applicant (Initials not allowed)

Last Name ----------------- First Name---------------------------

2. If you have ever changed your name, please indicate the previous
name(s) in full
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3. Sex(male/female).------------- 4. Date of Birth:------------------

5. Place of Birth: Village/Town-------------------------------------------------

District,------------------------- State and Country-------------------------

6. Father’s Full Name/Legal Guardian’s Full Name (including surname, if

any): (Initials not allowed)-----------------------------------------------------

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

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8. If married, Full Name of Spouse (including surname, if any). (Initials

not allowed)

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9. Present Residential Address, including Street No./Police station, village

and District (with PIN code)
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Telephone No./Mobile No.-------------------------------------------

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

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11. Permanent Address including Street No./Police station, village and

District (with PIN code)

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12. If you have not resided at the address given at Column (9)
continuously for the last five year, 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
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14. Other Details :

(a) Educational Qualifications:

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

employers:

(c) Reason for leaving last employment:

(d) Visible Distinguishing Mark:

15. Did you earlier operated any Private Security Agency or were its
partner, majority shareholder or Director? If yes then furnish the name,
address of the Agency and its license particulars.

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

Naturalisation: 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)
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18. Are any criminal proceedings pending against you before a Court in
India? If so, give name of Court, case number and offence
-----------------------------------------------------------------------------------

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19. 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)
Date
Place . . . . . . . . . . . . . . .

20. 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 whatever is not applicable.
 Form – II
(See rule 4)
FORM FOR VERIFICATION OF CHARACTER AND ANTECEDENTS
OF SECURITY GUARD AND SUPERVISOR

Thumb Impression * of the Applicant ……………………..

Signature of the Applicant . . . . . . . . . . . . . . . . . . . . .

For official use only

Form Number Name of the police station sent for police Date
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 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’ 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 YYYY

-----------------------------------------------------------------------------------

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
(addressess) 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 Qualification:

(b) Previous posts held if any along with name and address of employer:
-----------------------------------------------------------------------------------

-----------------------------------------------------------------------------------

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(c) Reason for leaving last employment

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(d) Visible Distinguishing Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(e) Height (cms) ------------------------------------------------

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

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

Naturalisation? 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 & 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.
-----------------------------------------------------------------------------------

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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)

* FOR OFFICE USE ONLY

File No. : . . . . . . . . . . . . . . . . . . . . . . . . . .: . . . . . . . . . . . . . . . . . . . . . . . . . .

Date issue of C&A Report.____________

(Signature of Police station In charge)

Name of Police Station___________

Name of Police District___________

*N.B. Cancel whatever is not applicable.

 Form V
(See rule 8)
APPLICATION FOR NEW LICENSE / RENEWAL OF LICENSE TO
ENGAGE IN THE BUSINESS OF PRIVATE SECURITY AGENCY

To
The Controlling Authority
____________________
____________________

The undersigned hereby applies for obtaining a license to run

the business of operating service in the area of Private Security Agencies

1. Full name of the applicant:

2. Nationality of the applicant:

3. Son / wife / daughter of:

4. Residential Address:

5. Address, where the applicant desires to start his Agency:

6. Name of the Private Security Agency:

7. Name and addresses of Proprietor, Partner, Majority shareholder,

Director and Chairman of the Agency:

8. Name and extent facilities available:

9. Qualification, of staff engaged for imparting instructions;

Name ---------------------------

Age ---------------------------

Designation ---------------------
10. Equipments which will be used for Security services
(a) Door Framed Metal Detector (DFMD)
(b) Hand Held Metal Detector (HHMD)
(c) Mine detector
(d) Others Detectors
(i) Wireless Telephones
(ii) Alarm Devices
(iii) Armoured Vehicles
(iv) Arms

11. The particulars of the uniform including colour in case applicant the
intends to use any uniform for the Private Security Guards and
Supervisors of the Agency:

12. Does the applicant intend to operate in more than one district? If so
the name of the Districts
1. _______________________ 2. ________________________
3. _______________________ 4. ________________________
5. _______________________

13. Does the applicant intend to operate in the entire state?

14. Does the applicant possesses the training facility in its own or will get
it on outsourcing basis? The name and address of training facility should
be furnished.

Signature
Name of the applicant
Address of the applicant

Telephone number of the applicant

Date of application

Enclosure:
1. Copy of current Income Tax Clearance Certificate
2. Affidavit as prescribed in section 7, sub-section (2) of the Act
3. Other enclosures
 FORM VII

(See rule 13)

FORM FOR APPEAL

An Appeal under section 14 of the Act

Appellant_______________________________________________

S/o_____________________ R/o___________________________
______________________________________________________

Versus

Controlling authority / _____________________________________

_______________________________________________________

The ____________ above named appeal to the _________ (State

Home Secretary) _____________ from the order of (Controlling
Authority) dated ______ day of ________ and against refusal of license
to run Private Security Agency__________ and sets forth the following
grounds of objection to the order appeal from namely__________

1._____________

2._____________

3._____________

4._____________

Enclosed list of documents

----------------------

Signature
Name and Designation of the Appellant

Date
Place
 Form VIII
(See rule 10)
REGISTER OF PARTICULARS

(Part-I Management details)

Sl. Name of Parent’s/ Present Permanent Nationality Date of

No. person(s) Father’s address Address & Joining/leaving
managing the name & phone phone No the Agency
Agency No.
1.

(Part II Private Security Guards and Supervisor)

Sl. Name Father’s Prese Date of Permanent Photo Badge Salary

No of name nt Joining/ Address graph No. with
Guard/ addre leaving the date
Super- ss & Agency
visor phone
No.
1.
2.

(Part III Customers)

Sl. Name of Address of Number and Date of Date of

No. Customer the place ranks of Commencement discontinuation
& phone where Security of services of services
No. Security is Guards
provided provided

(Part IV Duty Roster)

SI. Name of the Private Address of Whether Date and time Date and
No Security the palace provided commencement time of
Guard/Supervisor of duty with any of duty ending of
arms / duty
ammunition
 Form IX
(See rule 15)

PHOTO – IDENTITY CARD FOR PRIVATE SECURITY GUARD /

SUPERVISOR

(Name of the Private Security Agency)

Name: --------------------------------------------

Official Designation: --------------------------------------------

Identification No: --------------------------------------------

Date of issue: --------------------------------------------

Valid up to: --------------------------------------------

Signature of the cardholder: --------------------------------------------

Signature of the Issuing Authority

Official Seal