Police Clearance Certificate Application Form Page 2
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1
2Mobile Number
Telephone Number
E-Mail ID
5. References in your village or town or city
5.1 First Reference Name and Address
Mobile Number
Telephone Number
E-Mail ID
5.1 Second Reference Name and Address
Mobile Number
Telephone Number
E-Mail ID
6. Other details
Are any criminal proceedings pending against the applicant before a Court in India ? If Yes, please
YES
NO
furnish details in a separate sheet, along with documentary proof.
DECLARATION
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel documents of any other
country. I have not lost, surrendered or been deprived or citizenship of India. The information given by me in this form and enclosures is true and I am
solely responsible for its accuracy. I am aware that it is an offence under the Passports Act, 1967 to furnish any false information or to suppress any
material
information
with
a
view
to
obtaining
a
passport
or
any
other
travel
document.
I further declare that I have no other passport/travel document in my possession.
Place:
________________
________________________________________________
Signature OR Thumb Impression of Applicant
Date:
____________________
(Left Hand Thumb Impression if male and Right Hand Thumb
Impression if female)
Please submit your Passport, in original.
Please paste one recently taken colour photograph (passport size) on the space provided on the first page of the application form and attach
two more photographs.
Please attach photocopies of all relevant pages of your Passport and also Labour Contract signed with your company.
In case the applicant has been staying in Malawi for more than 3 months, please bring Police Clearance Certificate, in original, from the
Police Headquarters.
In certain cases, issuance of PCC may take three to four months.
Acceptance of application forms : strictly between 0900 hours and 1100 hours on all working days (Mondays through Friday), except
public holidays. For enquiries, please call on Phone No.01755337 between 1500 hours and 1600 hours on any working day (Mondays
through Friday), except public holidays.
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