3/25/25, 11:27 PM APPLICATION FORM FOR PCC
CONSULATE GENERAL OF INDIA
455 NORTH CITYFRONT PLAZA DRIVE, [NBC TOWER BUILDING],SUITE NO. 850, CHICAGO,
ILLINOIS 60611, USA
00-1-312-5950405, https://www.cgichicago.gov.in
APPLICATION FORM FOR POLICE CLEARANCE CERTIFICATE Generated On: Tuesday, March 25, 2025
11:26:15 PM
SERVICE REQUIRED
Application Reference Number 25-2001426546
Paste your unsigned
Purpose of PCC IMMIGRATION PURPOSES OTHER THAN CITIZENSHIP
recent color
Country for which PCC is required USA
photograph Size
2"X2"
PASSPORT DETAILS
Passport Number R5946307
Date of Issue (DD/MM/YYYY) 02/02/2018
Date of Expiry (DD/MM/YYYY) 01/02/2028
Place of Issue HYDERABAD
File Number HY7060883925518 Note: Please paste your unsigned recent color
photograph Size 2"X2" and Signature/Left
Hand Thumb Impression in the box provided
APPLICANT DETAILS above.
Applicant's Name DEEPTHI DAATLA
Date of Birth (DD/MM/YYYY) 30/08/1998
Place of Birth (Village/Town/City) KONDAPAKA
Gender FEMALE
Marital Status SEPARATED
Citizenship of India by BIRTH
PAN FFJPD6177Q
Voter Id
Educational Qualification GRADUATE AND ABOVE
Employment Type STUDENT
Organisation name
Aadhaar Number 341011695892
FAMILY DETAILS
Father's Name MOHAN DAATLA
Mother's Name VASANTHA DAATLA
Legal Guardian's Name
Spouse's Name
PERMANENT ADDRESS IN INDIA
1-15/3, KONDAPAKA, VEENAVANKA, VEENAVANKA
Address
Karimnagar, Telangana
PIN 505502
Mobile/Tel No. 8309783173
E-mail DATLADEEPTHIPATEL@GMAIL.COM
PRESENT ADDRESS IN COUNTRY OF DOMICILE
Address 2206, STRAWBERRY CT, EDISON NJ 08817, USA
Mobile/Tel No. 7325583068
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
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3/25/25, 11:27 PM APPLICATION FORM FOR PCC
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 offence
N
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 EDISON NJ
Signature/Left Hand Thumb Impression of Applicant
Date 25/03/2025
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