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Police Clearance Certificate Form

This document is a police clearance certificate form for an Indian citizen named Deepesh Rathi who is applying for citizenship in Australia. The form provides Deepesh's personal details like name, date of birth, address, passport information, and a self-declaration stating he owes allegiance to India and has not acquired citizenship in another country. It was completed on August 9, 2019 in Neemuch, Madhya Pradesh, India.

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Deepesh Rathi
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913 views1 page

Police Clearance Certificate Form

This document is a police clearance certificate form for an Indian citizen named Deepesh Rathi who is applying for citizenship in Australia. The form provides Deepesh's personal details like name, date of birth, address, passport information, and a self-declaration stating he owes allegiance to India and has not acquired citizenship in another country. It was completed on August 9, 2019 in Neemuch, Madhya Pradesh, India.

Uploaded by

Deepesh Rathi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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8/9/2019 Police Clearance Certificate Form

Police Clearance Certificate Form

Government of INDIA, Ministry of External Affairs

Application Reference Number 19-0011212248


Passport Details
Passport Number R5151998
Passport Issue Date 18/12/2017
Passport Expiry Date 17/12/2027
Place of Issue BHOPAL
Country for which PCC is required AUSTRALIA
Purpose for which PCC is required CITIZENSHIP/NATIONALITY APPLICATION
Applicant Details
Applicants Name DEEPESH RATHI
Date of Birth (DD/MM/YYYY) 14/11/1986
Place of Birth (Village/Town/City) NEEMUCH
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type SELF EMPLOYED
Educational Qualification GRADUATE AND ABOVE
Aadhaar Number 553877079346
PAN AOIPR4293L
Family Details
Fathers Name ARUN KUMAR RATHI
Mothers name MANORAMA RATHI
Spouses Name PALLAVI RATHI
Present Residential Address Details
2/1 SCHEME NO 3, BHAGESHWAR MANDIR ROAD NEEMUCH
Address
NEEMUCH NEEMUCH CANT MADHYA PRADESH
Pin 458441
Mobile/Tel No. 8447832229 / 07423223540
E-mail Id [email protected]
Permanent Residential Address Details
2/1 SCHEME NO 3, BHAGESHWAR MANDIR ROAD NEEMUCH
Address
NEEMUCH NEEMUCH CANT MADHYA PRADESH
Pin 458441
Mobile/Tel No. 8447832229 / 07423223540
Other Details
Have you ever been charged with criminal proceedings or is any
NO
arrest warrant/summon pending before a court in India?
Self Declaration

I owe allegiance to the sovereignty, unity and 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 and I affirm that the information given by me in
this form and the enclosures is true and I am solely responsible for its accuracy, and 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.

Place
Date 09/08/2019

https://portal1.passportindia.gov.in/AppOnlineProject/secure/pccApplicantSelfDeclarationAction 1/1

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