POLICE VERIFICATION FORM

(LICENCOR) (LICENSEE)
(PHOTO) (PHOTO)

1 Name of the licenser & present address &

Phone No.
2 Name of license
(Previous Address & Phone No.)
3 Address of the premises to be given on Leave &
License
4 Address of the Native Place
(Correspondence Address of the License)
5 Nature of work (of the license)

6 Office address of the Licensee

(Phone Number & Visiting Card)
7 Family members (details of member &
relationship & age) of the licensee
8 Reference of 2 known person
(full address & Phone No.) of the licensee
9 Agreement Period (date of commencement )

10 Name of the Agent with Phone Number

DECLARATION
Whatever is stated by me is absolutely true as per my knowledge & if it proves false it
shall be deemed in any consequences in either ways

Thanking you

(Licensee) FOR POLICE STATION