Annex 23B:
APPLICATION FOR A POLICE CLEARANCE CERTIFICATE
SURNAME *MAIDEN NAME GIVEN NAMES
DATE OF BIRTH (YR/MTH/DAY) PLACE OF BIRTH SOUTH AFRICAN ID NO
LAST RESIDENTIAL ADDRESS IN RSA CODE TEL OF ABOVE (CODE + NO)
LAST BUSINESS/ EMPLOYER’S ADDRESS IN RSA CODE TEL OF ABOVE (CODE + NO)
MAILING ADDRESS IN COUNTRY OF APPLICATION TEL OF ABOVE (CODE + NO) E-MAIL ADDRESS *If Applicable SIGNATURE: DATE: CODE
Note: This form is not a prescribed form from SAPS. It has been developed by the Department of Foreign Affairs to assist applicants . Attach full set of fingerprints, R59.00 banker’s draft or money order payable to South African Police Service. Send to: Criminal Record Centre, 1st Floor Sanlam Plaza West, Pretoria, 0001 If authentication by Department of Foreign Affairs is needed, include: Cover letter to Criminal Record Centre explaining arrangements made; and Cover letter to Legalisation Section indicating country in which certificate will be used.