PERSONAL PARTICULARS FORM

(To Be Filled in Duplicate)

1. NAME AND PARTICULARS: Application Number : CYBPCC2018020006

1). FullName: syed shahbaaz

2). Aliases, if any:

3). (a) Have you ever changed your name? Yes No

(b) If yes what was your previous name?

4). MaidenName (In case of married women/ widow) Applicant must

paste(35X45mm) one
5). Place Of Birth : Hyderabad Date Of Birth : 13-March-1989
photograph here with
6). Father's Name : Syed Omar half the signature on
the photograph and
7). Mother's Name: Rafath Sultana half on the
8). If you are a married women/widow, husband's name/wife's Name : application.
Uzma Unnisa

9). Purpose of visit abroad Employment

10). (a) Did you ever possess any other citizenship? Yes P No

(b) If yes, did your acquire Indian citizenship by registration or

naturalization?

2. INFORMATION TO BE FURNISHED:

1). Have you any time during the period of five years immediately preceding
Yes P No
the date of this application been convicted by a court in India for any criminal
Offence and sentenced to imprisonment?

2). Are any proceeding pending against you before a Criminal Court in India? Yes P No

3). Has a warrant or summons for your appearance, or a warrant for your arrest
or an order prohibiting you departure from India been issued by any court? Yes P No

3. PERSONAL DESCRIPTION:

1). Profession and Present occupation: Private Employee

2). Height: 180 Cm 3). Colour of eyes: Black

4).Colour of hair: Black 5). Visible distinguishing marks A mole on right wrist

4. ADDRESS:

1). Permanent Address: Plot no:23, ( 7-13/23),Alakaapoor Township, Puppulaguda, Cyberabad, Telanga

2). Present Address: Plot no:23, ( 7-13/23), Alakaapoor Township, Puppulaguda, Cyberabad,

3). If you have not resided at the above address continuously for the last two years, please
give the other address where you have resided during this period.

5. REFERENCE:
Name and Address of two responsible persons in your locality who would be prepared to vouch for
you.
1).Name: Asma sultana 2).Name: Asma sultana
Address: Address:
Alakaapoor Township,Puppulaguda,Cyberabad Alakaapoor Township,Puppulaguda,Cyberabad
Pin Code: 500085, Phone: 9392567234 Pin Code: 500085, Phone: 9392567234

Date:
Place: Signature of Applicant