FormI (See rule 3)

FormforverificationofAntecedentsofApplicant.

Thumb impression of the Applicant

Signature of the Applicant

FeeAmountRs.

Cash/

D.D.

NameofBank

D.D.No.

DateofIssue

Pleasereadtheinstructionscarefullybeforefillingtheform.PleasefillinBLOCK LETTERS:(CAUTION:Pleasefurnishcorrectinformation.Furnishingofincorrect informationorsuppressionofanyfactualinformationintheFormwillrenderthe candidateunsuitableforgrantoflicence.

1.Name of the applicant (initials not allowed)

LastName FirstName

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); (initials not allowed)

7.Mother’sFullName(includingsurname,ifany):(initialsnotallowed)

8.Ifmarried,FullNameofSpouse(includingsurname,ifany)(initialsnot

allowed)

9.PresentResidentialAddress,includingStreetNo./PoliceStation,village and District (with PIN Code)

TelephoneNo./MobileNo.

10.Please give the date since residing at the above-mentioned address: DD MM YY

11.PermanentAddressincludingStreetNo./PoliceStation,villageanddistrict

(withPIN Code)

12.IfyouhavenotresidedattheaddressgivenatCOLUMN(9)continuouslyforthelast five years,pleasefurnishtheotheraddress(addresses)with

duration(s)resided.YoushouldfurnishadditionalphotocopiesofthisFormforeach additionalplaceofstayduringthelastfiveyears.Formsmaybephotocopied,butphotographandsignatureinoriginalarerequiredoneachForm.

From……………..To…………….From………………To

…………………

13.Incaseofstayabroadparticularsofallplaceswhereyouhaveresidedfor more than one year after attaining the age of twenty-one years.

14.OtherDetails:

(a)Educational Qualifications:

(b)Previous positions held, if any, along with name and address of employers:

(c)Reasonsforleavinglastemployment: (d)Visible Distinguishing Mark :

15.DidyouearlieroperatedanyPrivateSecurityAgencyorwereitspartner, majorityshareholderorDirector?ifyes,thenfurnishthename,addressof theAgencyanditslicence,particulars.

16.Are you a citizen of India by: Birth/Descent/Registration/Naturalization:

ifyouhaveeverpossessedanyothercitizenship,pleaseindicateprevious citizenship

17.HaveyouatanytimebeenconvictedbyacourtinIndiaforanycriminal offenceand sentencedtoimprisonment?ifso,givenameofthecourt, casenumberandoffence.(Attachcopyofjudgment)

18.AreanycriminalproceedingspendingagainstyoubeforeacourtinIndia?

ifso,givenameofcourt,casenumberandoffence.

19.Self–Declaration:

TheinformationgivenbymeinthisFormandenclosuresistrueandIam solely responsible for accuracy.

Date……………… Place……………..

20.Enclosures:

(Signature/T.I*ofapplicant)

(Signature/T.I*ofapplicant)

(*LeftHandThumbImpressionifMaleandRightHandThumbimpressionif

Female)

FOROFFICEUSEONLY

FileNo.:………………………………………………………… DateofissueofCandAReport………………………………….

(SignatureofPoliceStationincharge)

Name of Police Station

NameofPoliceDistrict

•N.B.Cancelwhateverisnotapplicable.

Form II (Seerule4)

FormforverificationofCharacterandAntecedentsofPrivateSecurityGuardand

Supervisor.

Thumb impression* of the Applicant

SignatureoftheApplicant

Passport Size recent photograph attested by Gazetted Officer

Forofficialuseonly
FormNumber / Nameofthepolicestationtowhichsentfor police verification / Date

FeeAmountRs.

Cash/

D.D.

NameofBank

D.D.No.

DateofIssue

Pleasereadtheinstructionscarefullybeforefillingtheform.PleasefillinBLOCK LETTERS:(CAUTION:Pleasefurnishcorrectinformation.Furnishingofincorrect informationorsuppressionofanyfactualinformationintheFormwillrenderthe candidateunsuitableforemployment/engagementinthePrivateAgency.

1.Nameoftheapplicantasshouldappearinthephoto-identitycard(initials notallowed)

LastName FirstName

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); (initials not allowed)

7.Mother’sFullName(includingsurname,ifany):(initialsnotallowed)

8.Ifmarried,FullNameofSpouse(includingsurname,ifany)(initialsnot allowed)

9.PresentResidentialAddress,includingStreetNo./PoliceStation,village and District (with PIN Code)

TelephoneNo./MobileNo.

10.Please give the date since residing at the above-mentioned address: DD MM YY

11.PermanentAddressincludingStreetNo./PoliceStation,villageandDistrict

(withPIN Code)

12.IfyouhavenotresidedattheaddressgivenatCOLUMN(9)continuouslyforthelast five yearspleasefurnishtheotheraddress(addresses)withduration(s)resided.You shouldfurnishadditionalphotocopiesofthisFormforeachadditionalplaceofstay duringthelastfiveyears.Formsmaybephotocopied,butphotographandsignatureinoriginalarerequiredoneachForm.

From……………..To…………….From………………To

…………………

13.Incaseofstayabroadparticularsofallplaceswhereyouhaveresidedfor more than one year after attaining the age of twenty-one years.

14.OtherDetails:

(a)Educational Qualifications:

(b)Previouspositionsheld,ifany, alongwithnameandaddressofemployer:

(c)Reasonsforleavinglastemployment:

(d)VisibleDistinguishingMark:

(e)Height(cms)

15.Are you working in Central Government/State Govt/ PSU/ Statutory

Bodies.Yes/ No.

16.Are you a citizen of India by: Birth/Descent/Registration/Naturalization:

Ifyouhaveeverpossessedanyothercitizenship,pleaseindicateprevious

citizenship

17.HaveyouatanytimebeenconvictedbyacourtinIndiaforanycriminal offenceand sentencedtoimprisonment?Ifso,givenameofthecourt, casenumberandoffence.(Attachcopyofjudgment)

18.AreanycriminalproceedingspendingagainstyoubeforeacourtinIndia?

ifso,givenameofcourt,casenumberandoffence.

19.Hasanycourtissuedawarrantorsummonsforappearanceorwarrantfor arrestoranorderprohibitingyourdeparturefromIndia?Ifso,givename of court, case number and offence .

20.Self–Declaration:

TheinformationgivenbymeinthisformandenclosuresistrueandIam solely responsible for accuracy.

(Signature/T.I*ofapplicant) (*LeftHandThumbImpressionifMaleandRightHandThumbimpressionif

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*ofapplicant)

(*LeftHandThumbImpressionifMaleandRightHandThumbimpressionif

Female)

FOROFFICEUSEONLY

FileNo.:………………………………………………………… DateofissueofCandAReport…………………………………. (Signature of Police Station in charge)

NameofPoliceStation

NameofPoliceDistrict

*N.B.Cancelentriesnotapplicable.

Form–III (Seerule4)

CHARACTERANDANTECEDENTCERTIFICATE

ThisistocertifythatMr./Ms.

Son/Daughter/wifeof

whoseparticularsaregivenbelowhasgoodmoralcharacterandreputationand thattheapplicanthasbeenstayingatthefollowingaddresscontinuouslyforthe lastone-year.

DateofBirth: Place of Birth:

EducationalQualifications: Profession:

PresentAddress: PermanentAddress:

Issuing Authority

Signature Name Designation

DateofIssueAddress/Tel.No.

FormIV (Seerule5)

TrainingCertificate

SerialNumber:

NameoftheTrainingAgency AddressoftheTrainingAgency LicenceNo.

Certifiedthat

Son/daughter/wife of Shri

resident of

hascompletedtheprescribedtrainingfortheengagementoremploymentasa

PrivateSecurityGuardfrom

till

His/Hersignatureisattestedbelow.

SignatureoftheCertificate Holder

Signatureofissuingauthority

Designation

PlaceofIssue: DateofIssue:

FormV (Seerule8)

APPLICATION FOR NEW LICENCE/RENEWALOFLICENCETOENGAGEIN THE BUSINESS OF PRIVATE SECURITYAGENCY

To

TheControlling Authority

Theundersignedherebyappliesforobtainingalicencetorunthe businessofoperatingservicesinthearea of Private Security Agencies.

1.Fullnameoftheapplicant:

2.Nationality of the applicant:

3.Son/wife/daughterof:

4.ResidentialAddress:

5.Address,wheretheapplicantdesires to start his Agency:

6.NameofthePrivateSecurityAgency:

7.Name and addresses of Proprietor, Partner, Majority, Shareholder, DirectorandChairmanoftheAgency:

8.Nameandextentoffacilitiesavailable:

9.Qualificationsofstaff engaged for imparting instructions;

Name

Age

Designation

10.Equipmentswhichwillbeused for Security Services

(a)DoorFramedMetalDetector(DFMD) (b)HandHeldMetalDetector(HHMD)

(c)Mine Detector

(d)OtherDetectors

(i)WirelessTelephones

(ii)AlarmDevices

(iii)ArmoredVehicles

(iv)Arms.

11.The particulars of the uniform including colour in case the applicant intends to use any uniform for the Private Security Guards and Supervisors of the Agency:

12.Doestheapplicantpossessesthetrainingfacilityinitsownorwillgetiton outsourcing basis?Thenameandaddressoftrainingfacilityshouldbe furnished.

Signature Name of the applicant Address of the applicant

Telephonenumberofthe applicant

Dateofapplication

Enclosure:

1.CopyoflatestIncometaxClearanceCertificate.

2.AffidavitasprescribedunderSection 7 sub section (2) of the Act.

3.Otherenclosures.

FormVI (Seerule9)

GovernmentofPunjab

LICENCETOENGAGEINTHEBUSINESS OF PRIVATE SECURITY AGENCY

SerialNo.

Date

Shri/Ms. (name of the Applicant),

son/daughter/wife of

R/o

(FullAddress)

isgrantedthelicence

torunthebusinessofPrivateSecurityAgencyinthe StateofPunjabwithoffice at (address oftheoffice).

PlaceofIssue

Date of Issue

Thislicence isvalidupto

Signature NameofControlling Authority Designation

OfficialAddress

RENEWAL (Seerule11)

DateofRenewalDateofexpiry

1.

2.

3.

4.

Signature NameofControlling Authority Designation

OfficialAddress

FormVII (Seerule13)

FormforAppeal

AnAppealundersection14oftheAct

Appellant

S/o,D/O, W/O

r/o

Versus

ControllingAuthority,StateofPunjab,Chandigarh

The abovenamedappealismadeto the Principal Secretary to Government of Punjab, from the order dated

ofControllingAuthoritySSHandagainstrefusaloflicencetorun

PrivateSecurityAgencyintheStateofPunjab,Chandigarhandsetsforththe followinggroundsofobjections to the order: -

1.
2.
3.
4.

Enclosedlist of documents

Date: Place:

Signature

NameandDesignationoftheAppellant

FormVIII (Seerule14)

RegisterofParticulars

(Part–I Management details)

Sr. No / Nameof person (s) managin g / Parents’ Father’s Name / Present address and Phone No. / Permanent address / Nationality / Dateof joining/ leaving the agency
1.

(PartIIPrivateSecurityGuardsandSupervisor)

Sr.
No / Nameof
Supervisor / Father’s
name / Present
address and Phone No. / Dateof
Joinin- g/ leaving the agency / Perman-
ent address / Photograph / Badg-
eNo. / Salar
ywith date
1
2

(PartIIICustomers)

Sr.
No / Nameof
the
Customer
Phone
No. / Addressof
theplace where securityis provided / Numberand
ranksofPrivate SecurityGuards provided. / Dateof
commenc e-mentof services / Dateof
discontinu a-tionof theservice
1.

(PartIVDutyRoster)

Sr
No / Nameofthe
PrivateSecurity
Guard
/Supervisor / Addressof
theplace ofduty / Whether
providedany arms / ammunition / Dateandtime
of commence- mentofduty / Dateand
timeof endingof duty
1

Form- IX (Seerule15)

Photo-IdentitycardforPrivate SecurityGuard/Supervisor

(NameofthePrivateSecurityAgency)

Photograph of theholder dulyattested bytheissuing authority

Name:

OfficialDesignation:

IdentificationNo:

DateofIssue:

Validupto:

Signature of the cardholder:

Signatureof the issuing authority

OfficialSeal

Dr.B.C. GUPTA,

PrincipalSecretarytoGovernmentofPunjab, Department of Home Affairs and Justice.