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Request For Police Clearance Certificate: Form #461 Photo Requirement Sheet

This document contains instructions and a form for requesting a police clearance certificate from the Interests Section of the Islamic Republic of Iran in Washington D.C. It lists the required documents and a $82 money order (or $102 for outside the U.S.) to submit along with an application form requesting name, birth details, passport information, addresses and dates of previous visits to Iran. It notes failure to fully complete the form could result in the application being rejected.

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Dean Mante
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177 views2 pages

Request For Police Clearance Certificate: Form #461 Photo Requirement Sheet

This document contains instructions and a form for requesting a police clearance certificate from the Interests Section of the Islamic Republic of Iran in Washington D.C. It lists the required documents and a $82 money order (or $102 for outside the U.S.) to submit along with an application form requesting name, birth details, passport information, addresses and dates of previous visits to Iran. It notes failure to fully complete the form could result in the application being rejected.

Uploaded by

Dean Mante
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Form #461

‫بسمه تعالی‬
‫دفتر حفاظت منافع جمهوری اسالمی ایران – واشنگتن دیسی‬
EMBASSY OF PAKISTAN
INTERESTS SECTION OF THE ISLAMIC REPUBLIC OF IRAN
1250 23RD STREET N.W. SUITE # 200 WASHINGTON, DC 20037 TEL: (202) 965-4990 FAX: (202) 965-1073
WWW.DAFTAR.ORG E-MAIL: INFO@DAFTAR.ORG

Request for police clearance certificate

Please forward the following documents in order to receive a police clearance


certificate:

1- Original valid passport


2- Completion of attached Form #461
3- 8 passport photos based on the photo requirement sheet
4- 2 fingerprint forms (please do not fold)
5- Money order payable to the Embassy of Pakistan in the amount of $82 for
inside the U.S., and $102 for outside the U.S. (American Dollar)

Page 1 of 2 July 25, 2018


Form #461
‫بسمه تعالی‬
‫دفتر حفاظت منافع جمهوری اسالمی ایران – واشنگتن دیسی‬
EMBASSY OF PAKISTAN
INTERESTS SECTION OF THE ISLAMIC REPUBLIC OF IRAN
1250 23RD STREET N.W. SUITE # 200 WASHINGTON, DC 20037 TEL: (202) 965-4990 FAX: (202) 965-1073
WWW.DAFTAR.ORG E-MAIL: INFO@DAFTAR.ORG
APPLICATION FOR POLICE CLEARANCE
‫پرسشنامه متقاضیان عدم سوء پیشینه اتباع خارجی‬
‫محل الصاق عکس‬
 Please answer ONLY the English parts of the questionnaire.
 Failure to answer questions may result in rejection of your application. ‫توسط نمایندگی‬
 Type or print clearly.

1- First Name: :‫ نام‬-1


2- Last Name: :‫ نام خانوادگی‬-2
3- Middle Name: :‫ نام مستعار‬-3
4- Father's Name: :‫ نام پدر‬-4
5- Date and Place of Birth: :‫تاریخ و محل تولد‬-5
6- Sex: ( )Male ( ) Female ‫ ( ) مرد ( ) زن‬:‫جنس‬-6
7- Marital Status : ( ) Single ( ) Married ‫ ( ) مجرد ( ) متأهل‬: ‫ وضعیت تأهل‬-7
8- Nationality: : ‫ ملیت‬-5
9- Passport Number: :‫ شماره گذرنامه‬-9
10- Date an d Place of Issue of passport :‫ تاریخ و محل صدور گذرنامه‬:11
11- Date of Last Entry in to Iran: : ‫ تاریخ آخرین ورود به ایران‬-11
12- Purpose of your last trip to Iran: :‫ علت اقامت در ایران‬-12

13- Length of stay on your last trip to Iran : :‫ مدت اقامت در ایران‬-13
14- Occupation and Employment address in Iran : :‫ شغل و آدرس محل کار در ایران‬-14

15- Residential address in Iran: :‫ آدرس محل سکونت در ایران‬-15

16- Date of last departure from Iran: : ‫ تاریخ آخرین خروج از ایران‬-16
17- Port or airport of the last departure from Iran : ‫مرز آخرین خروج از ایران‬-17
Address and Phone Number In U.S.:
Street:
City: State: Zip Code:
Home Phone: ( ) _ _ _ - _ _ _ _ Cell Phone: ( ) _ _ _ - _ _ _ _ Work Phone: ( )___-____
Email:
Declare that the e above information Is true and correct. .‫مشخصات گذرنامه مندرج در فرم تأیید میگردد‬
Applicants Signature: ----------------

Date Signed:

Page 2 of 2 July 25, 2018

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