The _________ Police,
District Police Office,
Subject: Application for Issuance of PCC (POLICE CLEARANCE CERTIFICATE)
It is requested that a Police Clearance Certificate may be issued to me for visa purpose. My personal particulars are as follows:
Full Name : _________
Sex : _________
Previous Name : _________
Date of Birth : _________
Occupation : _________
Father (Full Name) : _________
Mother (Full Name) : _________
Spouse (Full Name) : _________
Permanent Address : _________.
Present Address : House _________.
Residing at current address since: _________
Passport No.: _________ Date of issue: _________ Valid till: _________
Passport issued by: Regional Passport Officer _________
Country for which Visa has been applied: _________
It is further stated that I am a citizen of _________ and have not been involved in any criminal case in _________ and that there is no criminal case pending against me in the Court of Law.
(Signature of Applicant)