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____________

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.________________________

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.