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Police Clearance Certificate Application

The document is a police clearance certificate application form submitted by Shri/Smt. Suraj Bind to the Vasco Police Station. It includes personal details such as the applicant's address, period of stay in Goa, contact number, and the purpose of the request for employment. The applicant declares that all provided information is accurate and has paid a fee of Rs. 200.

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10 views1 page

Police Clearance Certificate Application

The document is a police clearance certificate application form submitted by Shri/Smt. Suraj Bind to the Vasco Police Station. It includes personal details such as the applicant's address, period of stay in Goa, contact number, and the purpose of the request for employment. The applicant declares that all provided information is accurate and has paid a fee of Rs. 200.

Uploaded by

rajkammar52
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

Police

PCC Application Form

To, Date: 06-


01-2026
Vasco Police
Station Petition No

REQUEST FOR POLICE


CLEARANCE CERTIFICATE

Name(In Capital) : Shri/Smt. SURAJ BIND

Present Address : HNO 2/386 ,NEAR RASTROLI TEMPLE NEW


VADDEM VASCO DA GAMA ,Vasco City ,Mormugao ,South Goa , Goa -403802

Address During Stay in Goa


Place/Address of Stay during
Period Of Stay From Period Of Stay To
above Period
HNO 2/386 NEAR RASTROLI
01-01-2019 06-01-2026 TEMPLE NEW VADDEM
VASCO DA GAMA

Police Station : Vasco Police Station(Juridiction in which residence address falls)

Contact No. : 7972162582 (M)

Passport No. :
(Attested copy) of cover page

Reason / Purpose: FOR ALL JOB PURPOSE

Any Criminal Record:(Y/N) if yes,give details:N

Declaration:All the information furnished above is true to the best of my knowledge


Rs. 200/-
(Rupees two hundred only) Signature of applicant with date

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