5/20/25, 12:52 PM APPLICATION FORM FOR PCC

HIGH COMMISSION OF INDIA

SHAABAN ROBERT STREET, PLOT NO. 21351, P.O. BOX 2684, DAR ES SALAAM, TANZANIA
00-255-22-2113079, https://hcindiatz.gov.in/

APPLICATION FORM FOR POLICE CLEARANCE CERTIFICATE

Generated On: Tuesday, May 20, 2025 12:46:37
PM

SERVICE REQUIRED

Application Reference Number 25-2002625240

Paste your unsigned

Purpose of PCC EMPLOYMENT/EMPLOYMENT VISA/WORK PERMIT
recent color

Country for which PCC is required ZAMBIA

photograph Size
2"X2"
PASSPORT DETAILS

Passport Number N8954790

Date of Issue (DD/MM/YYYY) 24/03/2016

Date of Expiry (DD/MM/YYYY) 23/03/2026

Place of Issue BENGALURU

File Number BN2069181326116 Note: Please paste your unsigned recent color
photograph Size 2"X2" and Signature/Left
Hand Thumb Impression in the box provided
APPLICANT DETAILS above.
Applicant's Name ALLAN KIRAN DIAS
Date of Birth (DD/MM/YYYY) 02/10/1987
Place of Birth (Village/Town/City) KUNDAPUR KARNATAKA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN BQSPD3363A
Voter Id
Educational Qualification GRADUATE AND ABOVE
Employment Type PRIVATE
Organisation name
Aadhaar Number 840360458533

FAMILY DETAILS
Father's Name BORJA DIAS
Mother's Name METILDA DIAS
Legal Guardian's Name
Spouse's Name

PERMANENT ADDRESS IN INDIA

LF 1/4, 2ND CROSS, MICO LAYOUT, BTM LAYOUT 2ND S,
Address
BENGALURU, MICO LAYOUT Bengaluru, Karnataka
PIN 560076
Mobile/Tel No. 6362560789
E-mail ALLANKIRAN5@GMAIL.COM
PRESENT ADDRESS IN COUNTRY OF DOMICILE
Address HOTEL TUNDUMA, TUNDUMA TANZANIA, Tanzania
Mobile/Tel No. 260973125213

OTHER DETAILS
1) Provide the following details if there are any criminal proceedings pending against the applicant.
1.1) Are any proceedings in respect of an offence alleged to have been committed by you pending before a criminal court in India? N
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.2) Has any warrant or summons for your appearance been issued and pending before a court under any law for the time being in force? N
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.3) Has a warrant for your arrest been issued by a court under any law for the time being in force? N
Court Name and Place
Case/FIR/Warrant Number

about:blank 1/2
5/20/25, 12:52 PM APPLICATION FORM FOR PCC
Law and Section(s)
1.4) Has an order prohibiting your departure from India been made by any court? N
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
2) Provide the following details if the applicant has been convicted by a court in India.
2.1) Have you at any time during the period of five years immediately preceding the date of this application been convicted by a court in India for any criminal offence
N
involving moral turpitude and sentenced in respect thereof imprisonment for not less than 2 years?
Court Name and Place
Case/FIR/Warrant Number
Date of Conviction

SELF DECLARATION
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any other country. I have not lost,
surrendered or been deprived of the citizenship of India. I have not contravened any of the conditions relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing any material information in this regard. I
further affirm that the enclosures and documentary proof submitted in support of my application for an Indian passport are authentic and solely pertain to me and I am
fully responsible for the accuracy of the same. I am liable to be penalized or prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal
offence to furnish any false information or to suppress any material information with a view to obtaining passport or travel document.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me in the form is bonafide.

Place TUNDUMA
Signature/Left Hand Thumb Impression of Applicant
Date 20/05/2025

about:blank 2/2