Fillable Printable Application for Character Certificate
Fillable Printable Application for Character Certificate
Application for Character Certificate
Act 18/2012 - 10 October 2012 Ref : Dist/DD/MM/YYYY/Serial No
………./….../...…/….……./…………
PART 1 (to be filled by applicant - in block letters)
Receipt No ………………
1. Name of Applicant : (Surname) : . …………………………………… (Other Names) : ……………………………………..
(Alias) : ……………………………………. (Maiden Name if applicable) : ………………………
2. Date of Birth : …………………………………... Born in the district of : ………..………………………...
3. Identity Card No: Passport No. (foreigners) : ..……………….……
4. Home Address : ……………………………………………………………………………………………………………………
5. Phone No. Home : ………………………... Mobile : ………………………... Office : ………………………...
6. Marital Status : Single Married Divorced
7. Name of legal husband (if applicable: …………………………...………………… ………..………………………...
(Surname) (Other Name)
Name of Previous husband : ……………………………………..……….. ………..………………………...
(Surname)
(Other Name)
8. Have you ever been convicted by a court of law for any crime or misdemeanour ? Yes
No
If yes, please indicate date, place and nature of offence ……………………………………………………………………….
9. Have you ever been issued with a Certificate of Character ?
Yes No
If yes, When ? …………………………………………… ……………………………………………………………………….
10. Certificate required in :
English French
Date: ………………………
Signature of Applicant (or)
Authorised Representative
……………………………………………….
Part II (to be filled by employer on behalf of applicant in block letters)
I, Mr/Mrs/Miss ….………………………………………… from (company name) …………………………………………
apply on behalf of applicant.
Date : …………………. Signature : ………………………………………………
APPLICATION FOR CERTIFICATE OF CHARACTER
I, Mr/Mrs/Miss ….…………………………………… …………………………………………………………………………….
Acknowledge having on …….…../ ……..…/ ……...…. received my Certificate of Character and documents.
Part III - Acknowledgement (to be filled by applicant or on behalf of applicant in block letters)
Date : …………………. Signature : ………………………………………………
