GOVERNMENT OF INDIA MINISTRY OF HOME AFFAIRS *******

APPLICATION FORM FOR NON-OFFICIAL (TEMPORARY PASS)

Photo (3x3 cms) Front attested by sponsored authority to be pasted here

Part-I (To be filled by the applicant)

Photo (3x3 cms) to be pasted here Not to be attested)

1.

Name
(Block Letters) (First Name) (Middle Name) (Surname)

2. name

Fathers/ Husbands
(Block Latters) (First Name) (Middle Name) (Surname)

3. MM 4.

Date of Birth DD YY Sex

(Tick appropriate Box)

5.

Name of the Firm you are Associated with (as an Employee office bearer or in any other capacity) Designation Contractor/Labour/Daily wager Official address and Telephone No. Residential address & Telephone No.

6.

7.

8.

9. 10.

Mark of Identification Please specify the building(s) for which temporary pass is required 1 2

11.

Detailed justification for issue of a Non-Official Temporary Pass (Please given full and convincing justification for issue of a Non-Official Temporary Pass) along with the following documents.

NOTE: - The following documents must be enclosed with the application form. 1. 2. 3. Copy of valid contract. Name of the labourers specified by the contractor on letter head of he Company Firm. Character certificate from a Gazetted Officer.

CERTIFICATE
I certify that the information / answer given by me in part I of the application form are correct.

Signature of the Applicant Date: Place: The information furnished by the application has been verified to be correct.

Signatory of the Authorised Signature with Seal Place: Date: