DOMESTIC SERVANT/EMPLOYEE VERIFICATION FORM
PART I
SL. No. ____________POLICE STATION _______________ DISTRICT __________
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_________________________ District _____________________
State ____________________Country ____________________ Tel._______________________
7. Details of identification proof like Ration Card/Driving Licence/I.Card, if any _______________
_______________________________________________________________________________
8. Name & Address of the Sarpanch _________________________________________________
______________________________________________________________________________
9. Local Address _________________________________________________________________
______________________________________________________________________________
10. Name & address of previous employer in DNH
__________________________________________
___________________________________________________________Tel. No. ____________
11. Date since when employed
__________________________________________________________
12. 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) __________________________________________________
13. 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 __________________________________________________
14. Name & Local Address of Relatives & Friends in DNH ________________________________
.
________________________________________________________________________________
.
________________________________________________________________________________
15. INTRODUCED BY:-
Name, Address & Telphone No. ____________________________________________________
.
_________________________________________________________________________________
16. DETAILS OF EMPLOYER
Name, Address & Telephone No. ___________________________________________________
.
_________________________________________________________________________________
Signature of the Employer
FOR POLICE USE ONLY
PART – III
1. Form Prepared by
Name : ______________________________________ Rank ___________________________
Range No. ____________________________________ PIS No. _________________________
Police Station _________________________________ District __________________________
2. Result of verification from CRO ___________________________________________________
3. Result of verification from Finger Print Bureau _______________________________________
.
_________________________________________________________________________________
4. Result of verification from previous employers ________________________________________
_________________________________________________________________________________
5. Result of verification from the concerned Police Station _________________________________
(of DNH to be done local PS)
________________________________________________________________________________
________________________________________________________________________________
6. Details of verification form sent to DCP office for enquiry from SHO Home Town
PS ____________________________ District ______________________ State ________________
Despatch No. _____________________ Date ___________________
S.H.O __________________________
7. 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--
ACKNOWLEGEMENT
Received Servant/Employee verification form from Sh./Smt. __________________________________
in favour of Sh./Smt. __________________________________on ______________.
Signature of Duty officer
PS __________________
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
SERVANT VERIFICATION REGISTER
1. Sl. No.
2. Name & Address of employee
PHOTO
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
in DNH if any
12. Details of identity proof
himself or family members
13. Name and address of previous
employer, if any
14. Name of State/District where
from sent for verification
15. Verification result of local
enquiry by Police Station staff
16. Despatch detail/Date of
sending for out station
verification
17. Date of reply received
18. Address verified or not
19. Verification detail
20. Details of criminal record, if
any
21. Photograph
22. Finger Print taken or not
23. Remarks, if any
