HIGH COMMISSION OF INDIA

PLOT NO.11, KYADONDO ROAD NAKASERO, P.O.BOX 7040, KAMPALA, UGANDA

00-256-41-4344631, http://hci.gov.in/kampala/

APPLICATION FORM FOR POLICE CLEARANCE CERTIFICATE

Generated On: Wednesday, March 15, 2023
12:06:11

SERVICE REQUIRED

Application Reference Number 23-2001127452

Paste your
Purpose of PCC EMPLOYMENT/EMPLOYMENT VISA/WORK PERMIT
unsigned recent
Country for which PCC is required UGANDA color photograph
Size 2"X2"
PASSPORT DETAILS

Passport Number S035633

Date of Issue (DD/MM/YYYY) 16/04/2018

Date of Expiry (DD/MM/YYYY) 15/04/2028

Place of Issue COIMBATORE

File Number CB21C5018975118 Note: Please paste your unsigned recent color
photograph Size 2"X2" and Signature/Left Hand
APPLICANT DETAILS Thumb Impression in the box provided above.
Applicant's Name KRISHNARAJA SHANMUGAM
Date of Birth (DD/MM/YYYY) 15/03/1971
Place of Birth (Village/Town/City) METTUR
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN EAKPK4044L
Voter Id UUH0754259
Educational Qualification 10TH PASS AND ABOVE
Employment Type PRIVATE
Organisation name
Aadhaar Number 902122551010

FAMILY DETAILS
Father's Name SHANMUGAM M
Mother's Name PADMA S
Legal Guardian's Name
Spouse's Name REKHA K

PERMANENT ADDRESS IN INDIA

1/30NA REDDYAR STREET, THIPIREDDYYUR
Address MUKKANUR, DEEVATTIPATTY Salem rural, Tamil Nadu
PIN 636351
Mobile/Tel No. 9003600356
E-mail [email protected]
PRESENT ADDRESS IN COUNTRY OF DOMICILE
KIRYANDONGO SUGAR LIMITED, PO BOX 52 BWEYALE
Address
KIRYANDONGO, Uganda
Mobile/Tel No. 256757626425

OTHER DETAILS
1) Provide the following details if there are any criminal proceedings pending against the applicant.
1.1) Are any proceedings in respect of an offence alleged to have been committed by you pending before a criminal court in India? N
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.2) Has any warrant or summons for your appearance been issued and pending before a court under any law for the time being in force? N
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.3) Has a warrant for your arrest been issued by a court under any law for the time being in force? N
Court Name and Place
Case/FIR/Warrant Number

( )
Law and Section(s)
1.4) Has an order prohibiting your departure from India been made by any court? N
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
2) Provide the following details if the applicant has been convicted by a court in India.
2.1) Have you at any time during the period of five years immediately preceding the date of this application been convicted by a court in India for any criminal
N
offence involving moral turpitude and sentenced in respect thereof imprisonment for not less than 2 years?
Court Name and Place
Case/FIR/Warrant Number
Date of Conviction

SELF DECLARATION
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any other country. I have not lost,
surrendered or been deprived of the citizenship of India. I have not contravened any of the conditions relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing any material information in this
regard. I further affirm that the enclosures and documentary proof submitted in support of my application for an Indian passport are authentic and solely pertain
to me and I am fully responsible for the accuracy of the same. I am liable to be penalized or prosecuted if found otherwise. I am aware that under the Passports
Act, 1967 it is a criminal offence to furnish any false information or to suppress any material information with a view to obtaining passport or travel document.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me in the form is bonafide.

Place KIRYANDONGO
Signature/Left Hand Thumb Impression of Applicant
Date 15/03/2023