POLICE CLEARANCE CERTIFICATE APPLICATION FORM To The Superintendent of Police District Police Office, ……………………….., Subject: Application for issuance of PCC Sir, It is requested that a Police Clearance Certificate may be issued to me for RTI Organisation membership (RTI PCT) purpose. My personal particulars are as follows: Full Name (Expanded Initials)…………………………………………………………. Sex …………………………………………………………………………………….. Previous Name (in case the name has been changed) …………………………………. Date of Birth …………………………………………………………………………… Occupation ……………………………………………………………………………. Father (Full Name)……………………………………………………………………… Mother (Full Name) ……………………………………………………………………. Spouse (Full Name)……………………………………………………………………… Permanent Address ……………………………………………………………………… …………………………………………………………………………………………… Present Address ……………………….............................................................................. ........................................................................................................................................... Resident at current Address since ………………………………………………………… Passport No …………………………. Date of issue ………………. Valid till…………. I.D. issued by RTI Organization (India) under RTI PUBLIC CHARITABLE TRUST. It is further stated that I am a citizen of India and not involved in any criminal case in India and that there is no criminal case pending against me in the Court of Law.

(Signature of Applicant)

(Date)

Application must paste one photograph 35mm x 35mm here with half the signature on the photograph and half on the application