Formfor Verification of Antecedentsof Applicant

APPENDIX-I

Form1

(seerule 3)

Formfor verification of Antecedentsof Applicant

Thumb Impression* of the Applicant------Signature of the Applicant ------

AffixRecent Passportsize Photograph with Attestation

For OfficialUse Only
FormNumber / Nameof the policestation sent for police verification / Date

FeeAmount Rs------Cash/D.D,------Name of Bank-

------

D.D.No.------Date of Issue------

Pleasereadtheinstructionscarefullybeforefillingtheform.Pleasefillin BLOCK LETTERS: (CAUTION: Please furnish correct information. Furnishing of incorrect information or suppression of any factual informationintheformwillrenderthe candidateunsuitableforgrantof License)

1.Name ofapplicant (Initials notallowed)

Lastname ------First name------

2.If you have everchanged your name, please indicate the previous name(s) in full

………………………………………………………………………………………..

3.Sex (male/female). ------4. Date of Birth:------

---

5.Place of Birth: Village /Town------

6.Father’s full name /Legal Guardian’s full Name (including surname, if any)

(Initialsnot allowed)------

7.Mother’s Full Name (including surname, if any): (Initials notallowed)

…………………………………………………………………………………….

8.Ifmarried,FullnameofSpouse(including surname, ifany): (Initials not allowed)

………………………………………………………………………………………..

9.Present Residential Address, Including Street No/police station, village and District (withPIN code)

------

TelephoneNo./Mobile No.------

EmailID……………………………………………………………………………..

10. Pleasegivethedatesinceresidingattheabove-mentionedaddress:DD MM YYYY

------

11.PermanentAddressincludingStreetNo./Policestation,Villageand

District(with PINcode)

------

12. If you have not resided at the address given at COLUMN (9)continuously for the last five year, please furnish the otheraddress(addresses)withduration(s)resided.Youshouldfurnishadditionalphotocopiesofthisformforeachadditionalplaceofstayduringthelastfiveyear. Formsmaybephotocopied,butphotographandsignatureinoriginalarerequiredoneachform.

From------To------From------To------

------

13.Inthiscaseofstayabroadparticularsofallplacewhereyouhaveresided for more than one year afterattaining the age of twenty-one years.

------

14.Otherdetails :-

(a)Educational Qualifications:

(b)Details of theoccupation duringthelast 5years.

(c)Previous position held along with name and address of employer:- (d)Reason for leavinglast employment.

(e)VisibleDistinguishing Mark

15.Did you earlier operated any Private Security Agency or were its partner,majorityshare holderorDirector?Ifyesthenfurnishthename, address of the Agency and its LicenseParticulars.

------

16.AreyouacitizenofIndiaby:: Birth/Descent/Registration/Naturalization:

Ifyouhaveeverpossessedanyothercitizenship,pleaseindicateprevious citizenship

------

17.(a) Areanycriminalproceedingspendingagainstyoubeforeacourtin

India? If

So,givenameofcourt,case numberandoffence

(b)Have you been arrested by police/ any other Law enforcement agencyany

time?Ifso,Provide details ofsucharrests.

18.Haveyouatanytimebeenconvicted byacourtinIndiafor anycriminal’ offencesentencedto imprisonment?Ifso,givenameofthecourt,’case numberand offence.(Attach copy of judgment)

------

19.Detailedaddressesoftworespectablepersonsoftheareawherethe applicant resided in the last5 years.

------

20.Self Declaration;

Theinformationgivenbymeinthisformandenclosuresistrue and I am solely responsible for accuracy.

Date. Place………………..

21. Enclosures:

(Signature/T.I. * ofapplicant)

------

(Signature/T.I * ofapplicant) (* LeftHandThumbImpressionifMale andRightHandThumbImpression

ifFemale)

FOROFFICEUSEONLY

FileNo………………………………………………………………………….. Dateof issueof CA Report……………………………………………………

(Signatureof the Police station in Charge)

Nameof the Policestation………………………………………. Name of the policeDistrict………………………………………

*N.B.Cancelwhatever is not applicable

****

FormII

(seerule4)

Formfor verification of Characterandantecedents of Security Guardand Supervisor.

Thumb Impression* of the Applicant------Signature of the Applicant ------

AffixRecent Passportsize Photograph with Attestation

For OfficialUse Only
FormNumber / Nameof the policestation sent for police verification / Date

FeeAmount Rs------Cash/D.D.------Name of Bank-----

----

D.D.No.------Dateof Issue------

Please readtheinstructionscarefullybeforefillingtheform.Pleasefillin Blockletters:(CAUTION:Pleasefurnishcorrectinformationfurnishingof incorrectinformationorsuppressionofanyfactualinformationintheform willrenderthecandidateunsuitablefor employment/engagementinthe Private Agency.)

1.Nameofapplicantasshouldappearinthephoto-idenitycard(initialsnot allowed)

Lastname ………………………………First Name…………………………….

2.If you have ever changed your name, please indicate the previous name(s) in full

………………………………………………………………………………………..

3.Sex(male/female).------4.DateofBirth:------

---

5.Place of Birth: Village /Town------District,………………………………….StateCountry…………………………

6.Father’sfullname/LegalGuardian’sfullName(includingsurname,if any)

(Initialsnot allowed)------

7.Mother’s Full Name (including surname, if any): (Initials notallowed)

…………………………………………………………………………………….

8.Ifmarried,FullnameofSpouse(includingsurname,ifany):(Initialsnot allowed)

………………………………………………………………………………………..

9.PresentResidentialAddress,IncludingStreetNo/policestation,village and District (withPIN code)

------

TelephoneNo./MobileNo.------

10. Pleasegivethedatesinceresidingattheabove-mentionedaddress:DD MM YYYY

------

11.PermanentAddressincludingStreetNo./Policestation,Villageand

District(with PINcode)

------

12. If you have not resided at the address given at COLUMN (9)continuously for the last five years, please furnish the otheraddress(addresses) with duration (s) resided. You should furnishadditionalphotocopiesofthisformforeachadditionalplaceofstayduringthe last five years. Formsmay bephotocopied,butphotographandsignatureinoriginalarerequiredoneachform.

From------To------From------To------

------

13. In this case of stayabroad particulars of all places where you have resided for more than one year afterattaining the age of twenty-one years.

------

14.Otherdetails :-

(a)Educational Qualifications:

(b)Previous posts held along with nameand addressof employer

------

(c)Reason forleaving last employment------

------

------(d) Visible DistinguishingMark………………………………………

(e)Height (cms)………………………………………………………

15.AreyouworkinginCentralGovernment/StateGovt/PSU/Statutory

Bodies

Yes/No

16. AreyoucitizenacitizenofIndiaby:Birth/Descent/Registration/Name if you have ever possessed any other citizenship, please indicate previous citizenship.

------

17.Have youat any time been convictedby a courtin India forany criminal offence &Sentenced toimprisonment? If so, givename of thecourt,case numberand office. (Attach copyofJudgment)

------

18.Are any criminal proceedings pending againstyou before a courtin

India? Ifso,givenameofcourt,casednumberandoffence

------

19.Hasanycourtissuedawarrantorsummonsforappearance’orwarrant forarrestoranorderprohibitingyourdeparturefromIndia?Ifso,give name of court, casenumberand offence.

20.Self Declaration;

Theinformationgivenbymeinthisformandenclosuresistrue and I am solely responsible for accuracy.

Date. Place………………..

(Signature/T.I. * ofapplicant)

21.Particulars of person to be intimated. In the event of death or accident: Name------Address------

------

Mobile / Tel. No.------

22. Enclosures:

------

FOROFFICEUSEONLY

(Signature/T.I * ofapplicant)

FileNo………………………………………………… Dateof issueof CA Report………………………….

(Signatureof the Police station in charge)

Nameof the policestation………………………………………. Name of the PoliceDistrict………………………………………

*N.B. Cancelwhatever is not applicable

****

Form–III (see rules 3 &4)

CHARACTER AND ANTECEDENTCERTIFICATE

Thisis to certify that Mr/Ms………………………Son/Daughter of

……………………………………..Whoseparticularsaregivenbelowhas goodmoralcharacterandreputationandthattheapplicanthasbeenstaying at the followingaddress continuouslyfor the lastone year.

Dateof Birth

Place of Birth

Educational Qualification: Profession:

PresentAddress: Permanent/Address

Issuing Authority

Signature Name Designation

Address/Tel. No. Dateof Issue

****

FormIV (Seerule5(4))

Serial Number

Training Certificate

AffixRecent Passportsize Photograph with Attestation

Name of the Training Agency Address of the Training Agency Licence No

Certifiedthat …………………………Son/Daughter of ……………… resident of ………………has completed the prescribed training in the authorised training facility

Name………………….Address…………………situated / at
………………………….for the engagement or employment / asa / Private
SecurityGuard from…………………….Till……………….

HisSignature isattested below.

Signatureof the Certificate Holder

Signatureof issuing Authority

Designation

Place of issue

Dateof issue

****

FormV

(Seerule3,8 (a))

APPLICATION FOR NEW LICENCE TO ENGAGE IN THE BUSINESSOF PRIVATE SECURITY AGENCY

TheControlling Authority

AffixRecent Passportsize Photograph with Attestation

FingerPrints

Theundersigned hereby applies for obtaininga Licence to run the business of operating services in the areas of private / Security Agencies.

1. Full name of the applicant:

2. Nationality of theapplicant:

3. Son/Wife/Daughterof:

4. Residential Address:

5. Address, where theapplicantdesires to start his Agency.

6. (a)Nameof the Private Security Agency:

(b)Detailsof Registration of Agency in India:

7. Name andaddresses of Proprietor,Partner,Majorityshareholder

DirectorandChairman of the Agency:

8. Name and extent offacilities available:

9. Qualifications of Staff engaged for imparting instructions: Name…………………..

Age……………………. Designation…………

10.Equipments which will beused for

Securityservices

(a)Door FramedmetalDetector

(b)Hand Held MetalDetector(HHMD) (c)Mine detector

(d)Other Detectors

i.Wireless Telephones ii. Alarm Devices

iii.Armored Vehicles iv. Arms

11.TheParticularsoftheuniformincludingcolorincasetheapplicant intends to use any uniform for the private Security Guards and Supervisors of theAgency:

12.Doestheapplicantintendstooperateinmorethanonedistricts?ifso thename of the Districts

1234_5__

13.Does theapplicant intend to operate in the entire state?

14.Doestheapplicantpossessesthetrainingfacilityinitsownorwillgetin onoutsourcingbasis?Thenameandaddressoftrainingfacilityshould be furnished.

Signature Name of theapplicant Address of theapplication

Telephonenumberof the applicant Email ID of the Applicant Dateof application

Enclosure:

1. Copyof currentIncome taxClearance Certificate

2. Affidavitas prescribed in Section 7sub-section (2) of theAct

3. Other enclosures.

****

Form V (a) (Seerule3, 8 (b))

APPLICATION FOR RENEWL OFLICENCE TO ENGAGEIN THE

BUSINESS OF PRIVATE SECURITY AGENCY

TheControlling Authority

AffixRecent Passportsize Photograph with Attestation

FingerPrints

TheUndersigned hereby applies for obtaininga Licence to run the business of operating services in the area of Private /security Agencies

1. Full name of the applicant:

2. Nationality of theapplicant:

3. Son/Wife/Daughterof:

4. Residential Address:

5. Address, where theapplicantdesires to start his Agency.

6.(a)Name of thePrivate Security Agency:

(b)Detailsof Registration of Agency in India:

7. Name andaddresses of Proprietor,Partner,Majorityshareholder

DirectorandChairman of the Agency:

8. Name and extent offacilities available:

9. Qualifications of Staff engaged for imparting instructions: Name…………………..

Age……………………. Designation……………

10.Equipments which will beused for

Securityservices

a. Door FramedmetalDetector

b.Hand Held MetalDetector(HHMD)

c.Mine detector

d.Other Detectors

i.Wireless Telephones ii. Alarm Devices

iii.Armored Vehicles iv. Arms

11.TheParticularsoftheuniformincludingcolorincasetheapplicant

intendsto use any uniform for the private Security Guards and

Supervisors of theAgency:

12.Doestheapplicantintendstooperateinmorethanonedistricts?ifso thename of the Districts

1234_5__

13.Does theapplicant intend to operate in the entire state?

14.Doestheapplicantpossessesthetrainingfacilityinitsownorwillgetin onoutsourcingbasis?Thenameandaddressoftrainingfacilityshould be furnished.

15.Details of previous Licence

(i)Licence No. (ii) Date of Issue (iii)Date of expiry

16.DetailsofcancellationandsuspensionofLicencebyControlling

Authorityunder section 13 of the Act.

Enclosure:

Signature Name of theapplicant Address of theapplication

Telephonenumberof the applicant Email ID of the Applicant Dateof application

1.Copyof currentIncome taxClearance Certificate

2. Affidavitas prescribed in Section 7sub-section (2) of theAct

3. Other enclosures.

****

FormVI

(Seerule8 (a)and (b) GOVERNMENTOF

Licence toengage inthe business of Private SecurityAgency

SerialNO.------Date------

Shri------(Nameof the Applicant) S/o------r/o------

------(Full Address)------

------is Granted /Renewed theLicence by the Controlling Officer for the State of ------to run the business ofPrivate Security Agency in the district(s) of /State of (Strike

ofthe Inapplicablewords)------

------

------with office at ------(Address of the office)

Placeof IssueDateof Issue_

This Licence is validup to

Signature

Name of thegranting Authority Designation Official Address

RENEWAL

(see rule 8(a) &(b)

Dateof RenewalDateof expiry

Signature

Name of thegranting Authority Designation Official Address

****

FormVII

(Seerule 9)

Formfor Appeal

AnAppeal under section 14 of theAct

Appellant

S/or/o_

Versus

Controllingaughority/

The above namedappeal to the (State Home

Secretary)

Fromtheorderof(ControllingAuthority)dated

Day of

and against refusal of Licence to run Private

Security Agency_and against refusal of Licence to run PrivateSecurity Agency_ and sets forth the following grounds of objection to the order appeal from namely_ .

Enclosedlistofdocuments

Date

Place.

Signature

NameandDesignation of the Appellant.

****

FormVIII (Seerule10)

Registerof Particulars

(Part–IManagement details)

S.No. / Nameof person(s) Managing theAgency / Parents’s Father name / Presentaddress
PhoneNo / Permanent
Address / Nationality / Dateof Joining/leaving the Agency / Photo graph
1.

(PartII PrivateSecurity Guardsand supervisor)

Sl.No / Nameof the
Guard/Supervisor / Father’s
Name / Present
address
& Phone No / Dateof
Joining/leaving the Agency / Permanent
Address / Photo-
Graph / Badge
No. / Salary
with
Date / Finger
Prints

(PartIIICustomers)

Sl.No. / Nameof theCustomer &
PhoneNo / Addressof the
placewhere
securityis provided / Number And
Ranks of
Security Guards
Provided / Dateof
Commencement
Of Services / Dateof
Discontinuation
ofServices

(Part IV duty roster)

Sl.No. / Nameof thePrivate
Security Guard/ Supervisor / Addressof the
placeof duty / WhetherProvided
with
Arms/ammunition / Dateand time
of Commencement ofduty / Dateand time
ofendingor duty

Part V(SERVICEPARTICULARS)

Service particularsfor Security Guardand Supervisor

1.Name:

2.Post:

3.DateofBirth:

4.Dateof Appointment:

5.EducationalQualification:

6.NativeDistrictandState:

7.Rewards:

8.Punishments:

9.PreviousExperience: (if, any)

****

FormIX

(See Rule11)

Photo-IdentityCard for Private

Security Guard/Supervisor

(Name of the Private Security Agency)

Serial No:-

Name------. Official Designation------Identification no.------Blood Group:------Telephone No. &Mobile No.------Dateof issue------Valid up to------

Signatureof the cardholder------

AffixRecent Passportsize Photograph

Finger Prints

Signatureof

Issuingauthority

Official Seal

Onthe Back Side ofthe Photo ID Card

“Nameand Address and Telephone No. of the person to be contacted in case of Emergency.

****

FormX (see Rule 5)

Formfor List of Successful Trainees

Nameof the Training Institute:-

Sl.No / Nameof theTrainee / Addressof the
Trainee / Kind of
Training undergone / Durationof
Trainingwith dates / Remarks
1
2

Official Seal

Signature

IssuingAuthority.