DEPARTMENT OF POLICE, Delhi, India

.....

Please Print This Form & Submit The Same, After Filling It Up, To Your Nearest
Police Station.

VERIFICATION FORM FOR DOMESTIC SERVANT/EMPLOYEE

SI.NO. _________________________
Police Station_____________________Distt.___________________________________

1.	Name in full, with alias, if any _______________________________________ _______________________________________ _______________________________________
2.	Father's name____________________________________ Mother's name_________________________________
3.	Place and Date of birth_____________________________ _______________________________________________

4	Language spoken_____________________________________________ _________________________________________________________________
5. 6.	Permanent Address_________________________Vill.______________________ P.O.________________P.S.______________________Distt._________________ Name & Address of the Sarpanch_______________________________________ ___________________________________________________________________
7.	Local Address (with name of employer)______________________ ____________________________________________________
8.	Particulars/details of Ration card/Driving Licence/I..Card if any _______ ___________________________________________________________
9.	Name and Address of friends/relatives and other associated./ known domestic servants in Delhi________________________ ________________________________________________________________ _____________________________________ ___________________________ _________________________________________________________________
10	Name and Address of previous employers in Delhi__________________ _______________________________________________________________ _______________________________________________________________ ________________________________________________________________
11	By whom introduced to the employer, Name and Address of the surety. _________ ___________________________________________________ ___________________________________________________________________ ______________
12	Date since employed_________________________________________________
13.	A specialisation obtained in which area of domestic help like:- i) Cooking______________________________________ ii) Dusting & Utensil cleaning________________________ iii) Outdoor works___________________________________ iv) Attending guests/visitors____________________________ v) Attending phone calls etc.____________________________
14	Personal Description:- i) Height ____________________________ ii) Build _______________________________ iii) Hair __________________________________ iv) Complexion _____________________________ v) Tatoo Marks_______________________________ vi) Other Identification Marks ____________________ vii) Deformity or peculiarity if any __________________ viii) Petwords of speech _________________________ ix) His favourate ditty ______________________________ x) Signature of the employee/servant ____________________ XI) Handwriting specimen_____________________________
	Signature & Designation of Police Officer ................................................... Date: .........................................................Police Station____________

FOR POLICE USE ONLY

1. Form prepared by:
Name _____________________ Rank __________________
Range no.______________ P.S. __________________________
Distt. ___________________________

2.
Result of verification from C.R.O._______________________________________
__________________________________________________________________

3. Result of verification from finger print Bureau _______________________________
_____________________________________________________________________

4. Result of verification from previous employers ______________________________
_____________________________________________________________________

5. Result of verification from the concerned home police station out of Delhi, if applicable
____ ____________________________________________________________
_________________________________________________________________

Forward to S.H.O.______________________________________________________
for verification and return in original with a report in Col.. No.5, above on the employee's antecedents.

No.____________

Date ______________ S.H.O._______________________

P.S._________________________

Distt.________________________

Part-II

FINGER PRINT IMPRESSION OF THE EMPLOYEE/SERVANT(Given only voluntarily)

Full name with aliases ______________________________________________

Father's or husband's name _____________________________________________

Address _____________________________________________________________

P.S.Sl. No.__________________

RIGHT HAND

Right Thumb Right Index Right Middle Right Ring Right Little

Left Hand

Left Thumb Left Index Left Middle Left Ring Left Little

LEFT HAND RIGHT HAND

Plain prints of four fingers & thumbs taken simultaneously. Plain prints of four fingers & thumbs taken simultaneously.

Signature & Designation of Police Officer

Date: _________________ ....................... Police Stn._________________________