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ALL INDIA CRIME

PREVENTION ORGANIZATION
AICPO H.Q. : TA-105, Tughlakabad Extn. Kalkaji, New Delhi - 110019 (INDIA)
Phone : +91-011-29987492, 29982124, Telefax : +91-011-29981605
P. O. Box No. 4423, Kalkaji, New Delhi - 110019 (INDIA)
Website : www.aicpo.org
Email : info@aicpo.org

4 Passport
size color
photograph
to enclosed

APPLICATION FORM

Serial No.

For priority processing of your application, please complete all sections. Note : New Member

Renewal of Membership

APPLICANTS
APPLICANT
DESCRIPTION
DESCRIPTION

(Please attach your old Identity Card No._________________)

PERSONAL DESCRIPTION

Name (in full) : ................................................................................................................................................

Male

Married

Female

Unmarried.

Indian

NRI

Nationality .......................

Age:
S/o, D/o, W/o : ................................................................................................................................................ Date of Birth:
Educational Qualification :Your name, as you would like it to appear on your card (Please leave one blank space between each name)
Professional
Post Graduate
Graduate

Other Specify : ..............................................................

Height ........................ Blood Group ...............................
Color of Eyes ..................................................................
........................................................................................................................................................................ Color of Hair ...................................................................
Identification Mark ..........................................................
........................................................................................................................................................................ ........................................................................................
........................................................................................................................................................................ Social activities ..............................................................
You are prefer
Print Media
Electronic Media
Pin Code : .............................. Phone/Mob/Fax : ........................................................................................... You are interested for freelance join us a Press Media
as a Reporter/Writer/Correspondent & Crime Reporter/
Permanent Address : ......................................................................................................................................
Special Correspondent/Press Photographer etc.
Other specify ...................................................................
........................................................................................................................................................................
Language Known? Speak
Read
Write
........................................................................................................................................................................ 1) Hindi
2) English
........................................................................................................................................................................ Other specify .................................................................
Was the applicant ever convicted?
Yes
No
Pin Code : ............................. Phone/Mob/Fax : ............................................................................................. If so, give details ............................................................
Present Address : ............................................................................................................................................

ABOUT YOUR PROFESSION

REFERENCE

You are
Ex-Defence / Police Personal
Self Employee
Retired
Service
Business Your close Friends/Relatives (Name, Address & Ph.)
Other (Specify) _______________________ Nature of Profession _______________________________ 1. ...................................................................................
Enclose any one of the following : Id. Proof : Ration Card / Voter Card / Driving Licence / Passport / Pan card etc.

.......................................................................................
Office Name & Address ...................................................................................................................................
Ph/Mob ..........................................................................
..........................................................................................................................................................................
2. ...................................................................................
..........................................................................................................................................................................
Pin Code ................................. Ph/Mob/Fax ................................................................................................... .......................................................................................
Website ............................................................... Email .................................................................................. Ph/Mob ..........................................................................

DECLARATION OF APPLICANT
I undersigned hereby declare and affirm that I have read and understood the rules and regulations of All India Crime Prevention Organization and bind myself
Morally and Socially with these terms. That I owe allegiance to the sovereignty and integrity of the Indian Nation in its larger interest. That wont do any thing or act
against the rules of All India Crime Prevention Organization and if I am found guilty of any such crime, I shall be ready to face any disciplinary action as
deemed fit and proper by the competent authority and in such an eventually the management deserve the right to dispense with my membership.

I do hereby confirm that the contents given above are correct & true to the best of my knowledge and belief and oath has been concealed thereof. Hence thinking
myself eligible to become the AICPO member. I request you to grant me the membership of All India Crime Prevention Organization at your earliest.

I am enclosing herewith Bank Draft/Cheque/M.O./Postal Order for Rs. ................................................... No. ............................................. Dated ................................
in favor of All India Crime Prevention Organization payable at New Delhi.
Registration Fee Rs. 2,000/- only

Twenty years Membership Fee Rs. 11,000/- only

Annual Renewal Fee Rs. 1,100/- only

Five years Membership Fee Rs. 5,000/- only

Life Membership Fee Rs. 21,000/- only

Special Contributions and Donations ............................................................................................................................

Applicants Introduce by .......................................................................................................................................................................

Signature of Applicant

(For office use only), Card No. ................................................... Division ..................................................... Rank ..............................................................................
Code No. ............................................ Territory ....................................................... Date of Issue ............................................. Valid Up To .........................................
Specimen Signature of the Applicant in 3 Boxes.
Place
Date