PUDUCHERRY POLICE DOMESTIC SERVANT/EMPLOYEE VERIFICATION FORM PART I SL. No. ____________POLICE STATION _______________ SUB-DIVISION __________ DETAILS OF SERVANT/EMPLOYEE 1. Name of the Servant/Employee (with alias, if any) _______________________________________ 2. Father's Name ___________________________________________________ 3. Mother's Name __________________________________________________ Photograph of Servant/Employee 4. Place & Date of Birth _____________________________________________ 5. Language spoken ________________________________________________ 6. Permanent Address __________________Vill.___________________________________________ PO___________________ P.S_________________________ Sub-Div. _____________________ State ____________________Country ____________________ Tel._______________________ 7. Details of identification proof like Ration Card/Driving Licence/I.Card, if any _______________ 8. Local Address _________________________________________________________________ 9. Name & address of previous employer __________________________________________ ___________________________________________________________Tel. No. ____________ 10. Date since when employed __________________________________________________________ 11. A SPECIALIZATION OBTAINED IN WHICH AREA OF DOMESTIC HELP LIKE : (i) Cooking ________________________________________________________________ (ii) Dusting & Utensil cleaning _________________________________________________ (iii) Outdoor works ___________________________________________________________ (iv) Attending guest/visitors ____________________________________________________ (v) Attending phone calls _____________________________________________________ (vi) Any other (Please specify) __________________________________________________ 12. DESCRIPTION OF EMPLOYEE (i) Height ___________ (ii) Built _____________________________(iii) Eyes ________________ (iv) Hairs ____________ (v) Complexion _______________(vi) Tatoo Marks __________________ (vii) Other identification Marks _________________________________________________ (viii) Deformity or peculiarity if any _______________________________________________ (ix)Petwords of speech _____________________________ (x) Physical Built __________________ (x) Handwriting specimen ___________________________________________________________ (xi)Signature of the employee/servant __________________________________________________ 13. NAME & LOCAL ADDRESS OF RELATIVES & FRIENDS 14. INTRODUCED BY:- Name, Address & Telephone No. ____________________________________________________ . 15. DETAILS OF EMPLOYER Name, Address & Telephone No. ___________________________________________________ . Signature of the Employer PART - II -A FINGER PRINT IMPRESSION OF EMPLOYEE/SERVANT (voluntarily given to the employer) (To be filled up by Employer only) 1. Full name with aliases ___________________________________________________________ 2. Father's or husband's Name _______________________________________________________ 3. Address _______________________________________________________________________ 4. Police Station Sl. No. ____________________________________________________________ FINGER PRINT IMPRESSION OF SERVANT/EMPLOYEE RIGHT HAND Right Thumb Right Index Right Middle Right Ring Right Little LEFT HAND Left Little Left Ring Left Middle Left Index Left Thumb Signature of employee Signature of employer PART II - B RIGHT HAND IMPRESSION OF THE SERVANT/EMPLOYEE Plain prints of four fingers & thumbs taken simultaneously (Voluntarily given to the employer) (To be filled up by Employer only) Signature of employee Signature of employer PART II - C LEFT HAND IMPRESSION OF THE SERVANT/EMPLOYEE Plain prints of four fingers & thumbs taken simultaneously (Voluntarily given to the employer) (To be filled up by Employer only) Signature of employee Signature of employer FOR POLICE USE ONLY PART - III 1. Form Prepared by Name : ______________________________________ Rank ___________________________ Police Station _________________________________ Sub.Div. __________________________ 2. Result of verification from Finger Print Bureau _______________________________________ 3. Result of verification from previous employers ________________________________________ 4. Result of verification from the concerned Police Station _________________________________ 5. Result of verification from home town /Date & details of verification received from home town S.H.O __________________________ -----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-----x-- ACKNOWLEDGEMENT Received Servant/Employee verification form from Sh./Smt. __________________________________ in favour of Sh./Smt. __________________________________on ______________. Signature of the SHO PS __________________ SERVANT VERIFICATION REGISTER 1. Sl. No. PHOTO 2. Name & Address of employee 3. Name, address & telephone no. of employer Description of employee 4. Height 5. Eyes 6. Hairs 7. Complexion 8. Physical Built 9. Identification mark 10. Introduced by whom (Name, address & telephone numbers) 11. Details of Relatives & Friends, if any 12. Details of identity proof himself or family members 13. Name and address of previous employer, if any 14. Verification result of local enquiry by Police Station staff 15. Despatch detail/Date of sending for out station verification 16. Date of reply received 17. Address verified or not 18. Verification details 19. Details of criminal record, if any 20. Photograph 21. Finger Print taken or not 22. Remarks, if any 23. Signature of the SHO
