You will need to provide proof of identity together with your police certificate application form. This could be in the form of your passport and bank statements. Note that authentication of the information you fill out will be carried in various databases. Your certificate can be signed by you or a member of your family.
Title: Mr. / Mrs. / Miss/ Dr/ Other __________________________________________
Surname: ____________________________________________________________
Other names: _________________________________________________________
Sex: Female _____
Male_______
Nationality: __________________________________________________________
Passport No: __________________________________________________________
Date of birth: _________________________ Place of birth: ____________________
Your address: ________________________________________________________
Have you lived at this address for more than 5 years: _________________________
If not, provide details of your previous address including dates: ____________________________________________________________________
____________________________________________________________________
Telephone: ______________________________ E-mail:______________________
Have you faced criminal proceedings before? Yes No
Your contact details:
Telephone home: ________________________ office: ________________________
Fax: ___________________________________ e-mail: ________________________
What type of service do you require?
Premium ($40)
Standard ($80)
How many additional copies do you require? ____________________________
Mode of payment:
?Bankers check ?Postal Order ?Check
I declare that all the information supplied in this form is true
I authorize that inquiries can be made concerning the information given in this form
Signature: ___________________________________ Date: ______________________
………………………………………………….
