This template is designed to be a universal framework for a Police Clearance Certificate (PCC) or Criminal Record Check application. It covers the standard data points required by law enforcement agencies globally to verify an individual’s identity and conduct a background search.
Please provide your full legal details as they appear on your government-issued identification.
Full Surname (Family Name)
Given Name(s)
Maiden/Former Names
Date of Birth
Place of Birth (City, Country)
Gender
This section ensures the agency can reach you and verify your identity documents.
Primary Phone Number
Email Address
Passport Number
National ID Card Number
Driver’s License Number
Provide your current residential address and any previous addresses for the last 5–10 years to ensure a thorough records search.
Street Address
City
State/Province
Postal/ZipCode
Country
Street Address
City
State/Province
Postal/ZipCode
Country
Duration of Stay: From
To
Street Address
City
State/Province
Postal/ZipCode
Country
Duration of Stay: From
To
Provide additional addresses if necessary.
Street Address
City
State/Province
Postal/ZipCode
Country
Duration of Stay: From
To
Provide additional addresses if necessary.
Street Address
City
State/Province
Postal/ZipCode
Country
Duration of Stay: From
To
Agencies often categorize checks based on the sensitivity of the intended use.
Employment (General)
Employment (Working with Vulnerable Groups/Children)
Visa/Immigration/Residency
Adoption Purposes
Licensing (e.g., Security, Liquor, Medical)
Other:
Note: Some jurisdictions require a set of ink-rolled or digital fingerprints taken by an authorized official to accompany this form. Check if your specific authority requires an attached fingerprint card.
Read the following carefully before signing.
I, the undersigned, hereby certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false statements may lead to the rejection of this application or legal action.
Signature of Applicant
Application Reference Number
Date Received
Verification Officer Name
Status
Approved
Denied
Pending
Form Template Insights
Please remove this form template insights section before publishing.
The primary goal of this section is differentiation. In any large database, there are likely dozens of individuals with the same name.
This section acts as a bridge between the physical person and their digital record.
Criminal records are often stored in regional or precinct-based databases.
Why the applicant needs the form often dictates the depth of the search.
Fingerprints are the only way to achieve near 100% certainty in record matching.
This section is about accountability and consent.
This section is for the "paper trail."
Mandatory Questions Recommendation
Please remove this mandatory questions recommendation before publishing.
This is the primary search term for any records database.
This serves as the first and most important numerical filter.
This provides a geographic anchor for the identity.
This establishes the applicant's current jurisdiction.
This provides a verified link to a master identity registry.
The reason for the check dictates the parameters of the search.
To configure an element, select it on the form.