Annex 23B:

APPLICATION FOR A POLICE

CLEARANCE CERTIFICATE

SURNAME

*MAIDEN NAME

GIVEN NAMES

DATE OF BIRTH (YR/MTH/DAY)

PLACE OF BIRTH

SOUTH AFRICAN ID NO

LAST RESIDENTIAL
ADDRESS IN RSA

CODE

TEL OF ABOVE (CODE + NO)

LAST BUSINESS/
EMPLOYERS ADDRESS IN RSA

CODE

TEL OF ABOVE (CODE + NO)

MAILING ADDRESS
IN COUNTRY OF

APPLICATION CODE

TEL OF ABOVE (CODE + NO)

E-MAIL ADDRESS

*If Applicable
SIGNATURE: DATE:

Note:
This form is not a prescribed form from SAPS. It has been developed by the Department of Foreign
Affairs to assist applicants.
Attach full set of fingerprints, copy of ID document/passport, ZAR59-00 bankers draft, money order or
proof of electronic payment to the National Commissioner of the South African Police Service.
Send to: Criminal Record Centre, 1st Floor, Room 14, Botongo Plaza West, 271 Schoeman Street,
Pretoria, 0001, Republic of South Africa.
If authentication by Department of Foreign Affairs is needed, include:
Cover letter to SAPS - Criminal Record Centre explaining arrangements made; and
Cover letter to the Department of Foreign Affairs - Legalisation Section indicating country in which
certificate will be used.