Nagpur City

Application cum Personal Particulars Form for Character & Antecedents Verification

: , Ajni P. Station .

Nagpur City Nagpur City HIBISCUS HOLIDAYS

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Applicant's Name PATIL VIJAY BHIMRAO Application ID NGPR10171003132

ID Name Aadhar Card ID No 907090941215

Aadhar Card No. Mobile No. 9009760097

Email ID

Present Residential Address

C/0 SHIVKUMAR GOMARAO ATHANKAR, NEAR SALAWAN BUDDHA VIHAR GHAR NO 3612/A/D/2 NEAR SALAWAN
BUDDHA VIHARBHAGWAN NAGAR Nagpur (M Corp.) Nagpur (Urban) Nagpur MAHARASHTRA-440027
Previous Address

Do you need to verify your previous address

Address

Native/ Permanent Address

C/0 SHIVKUMAR GOMARAO ATHANKAR, NEAR SALAWAN BUDDHA VIHAR GHAR NO 3612/A/D/2 NEAR SALAWAN
BUDDHA VIHAR BHAGWAN NAGAR Nagpur (M Corp.) Nagpur (Urban) Nagpur MAHARASHTRA 440027
Company Name and Address where NOC/ Certificate is submitted

Designation DRIVER Company HIBISCUS HOLIDAYS

AddressPLOT NO. 111 MANEWADA ROAD NEAR SIDDHESHWAR HALL KHANKHOJE NAGAR Nagpur (M
Corp.) Nagpur (Urban) Nagpur MAHARASHTRA 440024
Particulars of places where the Applicant has resides during last 10 years
Sr. NoAddressFromTo
Pincode

1 MQ 1968, WARD NO 32, SHAKTI NAGAR, SHOBHA COLONY, 06/1980 10/2016 460449
SHOBHAPUR, PATHAKHEDA, BETUL, MP

Present Occupation / Service ( Joining date, Post, Office Address & Telephone)
30/10/2017

Visible Identification Mark

Have you been Arrested / Prosecuted? If yes, give case details ( C.R. No. & P.Stn )
No

Have you been Active in Politics? If yes, give details of the party / organisation.
No

Is there any Criminal Offence registered against you?

No
Name, Address & Signature of two persons in your locality who knows you.
Name & Address
SHIVKUMAR GOMARAO ATHANKAR GHAR NO 3612/A/D/2, NEAR SALAWAN BUDD Mobile No.
VINOD MALIK GAYAPRASAD KI CHOWL, RAMESHWAR RD., OPP. JIVAN SCHOOL 7304985517
8149117932

I hereby solemnly state that information provided above by me is true and correct.

Place NAGPUR
Date 31/10/2017 Applicant's Signature