FORM II
( see rule 4)
FORM FOR VERIFICATION OF CHARACTER AND ANTECEDENTS OF
SECURITY GUARD AND SUPERVISOR IN PRIVATE SECURITY AGENCY
Thumb Impression* of the Applicant ___________________
Signature of the Applicant ___________________________
For official use only
Form Number Name of the police station Date
sent for police verification
Fee Amount Rs.** ________________________ Name of Bank
____________________________ D.D. No. ***_________________
Date of Issue ___________________
** Fee shall be Rs.1000/- (Rupees one thousand only) for applicants whose
domicile is within the state and Rs.2000/- (Rupees two thousand only) for those
who are outside the State.
*** The fee amount shall be in the form of Demand Draft or Bankers cheque
drawn in favour of the “Director General of Police, Tamil Nadu, Chennai–600 004”.
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 photo identity 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 and
Country_____________________________
6. Father’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 Door No., Street
Name/police station, village,Taluk and District (with PIN Code) :
____________________________________________________
Telephone No./Mobile No. _____________________
10. Please give the date from which he is residing at the above
mentioned address: DD/MM / YYYY
_________________________________________
11. Permanent Address including Door No., Street Name/police
station, village, Taluk 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 (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.
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 twenty–
one years
________________________________________
14. Other Details:
(a) Educational Qualifications: ______________________
(b) Previous posts held along with name and address of
employer: _____________________________
(c) Reason for leaving last employment:
___________________
(d) Visible Distinguishing Mark: _________________________
(e) Height (cms) _______________________
15. Are you working in Central Government/State Govt./Public Sector
Undertaking / Statutory Bodies Yes/No
16. Are you a citizen of India by: Birth / Decent / 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
judgement)
_________________________________________
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. Self Declaration:
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
File No.: ______________________
Date of issue of Character and Antecedents Report : ____________________
(Signature of the Officer in-charge of the Police station)
Name of Police Station _____________________
Name of Police District _____________________
*N.B. Cancel entries not applicable.
