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1 3/2/2021 application form FOR PCC1/3 CONSULATE GENERAL OF INDIALEVEL 1, 265 CASTLEREAGH STREET SYDNEY, NSW 2000, AUSTRALIA00-61-2-92232702, form FOR POLICE CLEARANCE CERTIFICATEG enerated On: 3/2/2021, 5:21:23 AMSERVICE REQUIREDA pplication Reference Number21-2000765940 Purpose of PCCRESIDENCE PERMITC ountry for which PCC is requiredAUSTRALIAPASSPORT DETAILSP assport NumberN00000 Date of Issue (DD/MM/YYYY)24/11/2018 Date of Expiry (DD/MM/YYYY)24/11/2027 Place of IssueSYDNEYFile Number00000000 APPLICANT DETAILSA pplicant's NameTEST TESTDate of Birth (DD/MM/YYYY)05/05/1990 Place of Birth (Village/Town/City)

2 MUMBAIG enderMALEM arital StatusSINGLEC itizenship of India byBIRTHPANV oter IdEducational Qualification7TH PASS OR LESSE mployment TypeOTHERSO rganisation nameAadhaar NumberNote: Please paste your unsigned recent color photograph Size 2"X2" and Signature/Left Hand Thumb Impression in the box provided DETAILSF ather's NameTESTM other's NameTESTL egal Guardian's NameTESTS pouse's NamePERMANENT ADDRESS IN INDIAA ddressTEST, TEST, AMBERNATHTHANE CITY, MAHARASHTRAPIN400602 Mobile/Tel ADDRESS IN COUNTRY OF DOMICILEP aste yourunsignedrecent colorphotographSize 2"X2" photographSize 2"X2"Paste yourAs per your current PassportAs per your current PassportAs per your current PassportAs per your current Passport0000000000000000As per the last page of your current passportSignature as per current passportAs per current passportSelect as per your requirementAUSTRALIA or CANADA per your current passportAs per current passportAs per current passportMention your marital statusMention your education

3 QualificationMention your employment typeAs per your current passportAs per your current passport As per your current passport As per current passport (or) if address is changed then enter current address Enter contact numberEnter your email address Select as per the Jurisdiction, AUSTRALIA Generated On: 2021, 5:21:23 AMSAMPLE application form FOR PCCAPPLICATION form FOR POLICE CLEARANCE CERTIFICATESAMPLE form ONLYSAMPLE form ONLYSAMPLE 3/2/2021 application form FOR PCC2/3 AddressTEST, TESTTEST, AUSTRALIAM obile/Tel DETAILSHave you ever been charged with criminal proceedings or is any arrestwarrant/summon pending before a court in India?

4 NO1) Provide the following details if there are any criminal proceedingspending against the ) Are any proceedings in respect of an offence alleged to have beencommitted by you pending before a criminal court in India?NCourt Name and PlaceCase/FIR/Warrant NumberLaw and Section(s) ) Has any warrant or summons for your appearance been issued andpending before a court under any law for the time being in force?NCourt Name and PlaceCase/FIR/Warrant NumberLaw and Section(s) ) Has a warrant for your arrest been issued by a court under any lawfor the time being in force?

5 NCourt Name and PlaceCase/FIR/Warrant NumberLaw and Section(s) ) Has an order prohibiting your departure from India been made byany court?NCourt Name and PlaceCase/FIR/Warrant NumberLaw and Section(s)2) Provide the following details if the applicant has been convicted by acourt in ) Have you at any time during the period of five years immediatelypreceding the date of this application been convicted by a court in Indiafor any criminal offence involving moral turpitude and sentenced inrespect thereof imprisonment for not less than 2 years?NCourt Name and PlaceCase/FIR/Warrant NumberDate of ConvictionSELF DECLARATIONI owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any other have not lost, surrendered or been deprived of the citizenship of India.

6 I have not contravened any of the conditions relating to the possessionand 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 materialinformation in this regard. I further affirm that the enclosures and documentary proof submitted in support of my application for an Indian passportare 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 foundotherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false information or to suppress any materialinformation with a view to obtaining passport or travel document.

7 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 SYDNEYDate 02/03/2021 Signature/Left Hand Thumb Impression of ApplicantEnter your Address in Australia Enter your contact numberSAMPLE form ONLY2021 SAMPLE 3/2/2021 application form FOR PCC3/3 Signature as per current passport2021 SAMPLE