<p> POLICE VERIFICATION FORM</p><p>(LICENCOR) (LICENSEE) (PHOTO) (PHOTO)</p><p>1 Name of the licenser & present address & Phone No. 2 Name of license (Previous Address & Phone No.) 3 Address of the premises to be given on Leave & License 4 Address of the Native Place (Correspondence Address of the License) 5 Nature of work (of the license)</p><p>6 Office address of the Licensee (Phone Number & Visiting Card) 7 Family members (details of member & relationship & age) of the licensee 8 Reference of 2 known person (full address & Phone No.) of the licensee 9 Agreement Period (date of commencement )</p><p>10 Name of the Agent with Phone Number</p><p>DECLARATION Whatever is stated by me is absolutely true as per my knowledge & if it proves false it shall be deemed in any consequences in either ways</p><p>Thanking you</p><p>(Licensee) FOR POLICE STATION</p>