EMBASSY OF INDIA
6-8 ULITSA VORONTOSOVO POLYE, MOSCOW, 105064, RUSSIAN FEDERATION
00-7-495-7837535, https://indianembassy-moscow.gov.in/
APPLICATION FORM FOR POLICE CLEARANCE CERTIFICATE
Generated On: Thursday, February 13, 2025
17:27:21
SERVICE REQUIRED
Application Reference Number 25-2000878732
Paste your
Purpose of PCC RESIDENCE PERMIT
unsigned recent
Country for which PCC is required RUSSIA color photograph
Size 2"X2"
PASSPORT DETAILS
Passport Number T3225320
Date of Issue (DD/MM/YYYY) 23/04/2019
Date of Expiry (DD/MM/YYYY) 22/04/2029
Place of Issue DELHI
File Number DL2063432472219 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 SIBYLIN JOY SANTHOSH
Date of Birth (DD/MM/YYYY) 26/02/2001
Place of Birth (Village/Town/City) CHENGANNUR KERALA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN MAFPS4422K
Voter Id
Educational Qualification 10TH PASS AND ABOVE
Employment Type STUDENT
Organisation name
Aadhaar Number 307942912540
FAMILY DETAILS
Father's Name SANTHOSH JOY THOMAS
Mother's Name LEENA SANTHOSH
Legal Guardian's Name
Spouse's Name
PERMANENT ADDRESS IN INDIA
JC - 52 B, HARI ENCLAVE, HARI NAGAR, HARI NAGAR,
Address HARI NAGAR West Delhi, Delhi
PIN 110064
Mobile/Tel No. 919899213855
E-mail SIBYLIN44K@GMAIL.COM
PRESENT ADDRESS IN COUNTRY OF DOMICILE
ULITSA VOROSHILOVA 7, ROOM NO. 207,, SARANSK,
Address
REPUBLIC OF MORDOVIA, 430010 , Russia
Mobile/Tel No. 89961182625
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.
SARANSK,
Place
RUSSIA
Signature/Left Hand Thumb Impression of Applicant
Date 13/02/2025
