For office use only

Total Periods for this Application

Reference No: ..

Checked by

APPLICATION FOR POLICE CLEARANCE CERTIFICATE POLICE HEADQUARTERS, COLOMBO 01, SRI LANKA
(PLEASE FILL IN BLOCK LETTERS)

1. Applicants Name in full: 2. NIC Number : 3. Reference High Commission/Embassy : 4. Passport Number: 5. Nationality: 6. Date of Birth : 7. Occupation: 8. Purpose : Residence Visa 9. Status : Rev. Temporary Visa Married Employment Unmarried Student Scholarship Sex: Male Female

10. Have you applied for a certificate previously? Yes No Country 11. If so, was a certificate issued to you: Reference No: 12. Present address in Sri Lanka: 13. Present address: (Overseas) 14. Places of residence for the period certificate is required: (If insufficient space, give details on an attachment) Addresses Police Area Date From To Yes No Date of issue:

* If police area incorrectly filled, your clearance certificate could delay. Page: 1 of 3

15. The period for which the certificate is required : Less than one year 1 to 5 years 5 to 10 years

If others (specify) : 16. Indicate address of the High Commission/Embassy/Consulate to which the certificate should be addressed to:

17. Indicate the address the police clearance certificate should be posted to:

18. Telephone Number in Sri Lanka : 19. Email Address: .

.. Date

.. Signature of Applicant

For office use only Date :

Reference Number :
Police Station Date Sent Date Returned Remarks

SIS CID TID Dept. Of Registration of Persons (NIC) BR Number : .

Date of Issue : . Manner of dispatch Posted

Page: 2 of 3

Details of Spouse (If applicable only)

01.

(a).

Spouses Full Name :-

(b). Nationality :(c). Passport No.:(d). NIC No. :02. In addition to the details provided in page 01, the addresses of the places where the applicant and spouse lived since birth, both in Sri Lanka and overseas with the relevant Police Area in Sri Lanka to be stated.

Applicants Address

Spouses Address

.. Date

Signature of Applicant.

Page: 3 - 3