Download Form For Verification Of Antecedents Of Applicant

Home Department Form - I (See rule 3) FORM FOR VERIFICATION OF ANTECEDENTS OF APPLICANT Thumb Impression * of the Applicant .......... SignatureoftheApplicant........... .......... For official use only Form Number Name of the police station sent for police verification Date Fee Amount Rs.­­­­­­­­­­­­­­Cash/D.D­­­­­­­­­­­­­­­Name 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 3. Sex(male/female).­­­­­­­­­­­­­4. Date of Birth:­­­­­­­­­­­­­­­­­­ 5. Place of Birth: Village/Town­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­District,­­­­­­­­­­­­­­­­­­­­­­­­­State and Country­­­­­­­­­­­­­­­­­­­­­­­­­ 6. Father's Full Name/Legal Guardian's 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 above­mentioned 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 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. 13. In case of stay abroad particulars of all places where you have resided for more than one year after attaining the age of twenty­one years From.......To..........From..........To............ 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) ............................................................... ...... ......................................................... 18. Are any criminal proceedings pending against you before a Court in India? If so, give name of Court, case number and offence ............................................................... ...... ......................................................... ............................................................... 19. Self­Declaration: 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 FileNo.:........................: .......................... 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 .......... SignatureoftheApplicant........... .......... For official use only Form Number Name of the police station sent for police verification Date Fee Amount Rs.­­­­­­­­­­­­­­Cash/D.D­­­­­­­­­­­­­­­Name 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 photo­identity 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 above­mentioned 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 twenty­one years 14. Other Details: (a) Educational Qualification: (b) Previous posts held if any along with name and address of employer: (c) Reason for leaving last employment (d)VisibleDistinguishingMark...................... ... .. ... ... (e) Height(cms) ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ 15. Are you working in Central Government/State Govt/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. ............................................................... ...... ................. ....................................... ............................................... 20. Self­Declaration: 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 FileNo.:........................ ..:. ..... ... ... ..... ......... 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 intends to operate in more than one districts? 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, sub­section (2) of the Act 3. Other enclosures : 20 : 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 (Part­I Management details) Sl. No. Name of person(s) managing the Agency Parent's/ Father's name Present address & phone No. Permanent Address & phone No Nationality Date of Joining/leaving the Agency 1. (Part II Private Security Guards and Supervisor) Sl. No Name of Guard/ Super­visor Father's name Prese nt addre ss & phone No. Date of Joining/ leaving the Agency Permanent Address Photo graph Badge No. Salary with date 1. 2. (Part III Customers) Sl. No. Name of Customer & phone No. Address of the place where Security is provided Number and ranks of Security Guards provided Date of Commencement of services Date of discontinuation of services (Part IV Duty Roster) SI. No Name of the Private Security Guard/Supervis or Address of the palace of duty Whether provided with any arms/ammunition Date and time commence ment of duty Date and time of ending of duty 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