10/14/13

Application Form

PASSPORT APPLICATION FORM Government of INDIA,Ministry of External Affairs

Service Required
Application Reference Number Applying For Type of Application Type of Passport Booklet Validity Required 13-0011726258 FRESH NORMAL NORMAL NA DHARMRAJ PRASAD 05/02/1992 ONDA NALANDA BIHAR INDIA MALE SINGLE BIRTH STUDENT N 10TH PASS AND ABOVE Y MOLE ON FOREHEAD INDRAJIT PRASAD KANCHAN DEVI 08/2010 BIRLA INSTITUTE OF APPLIED SCIENCES BHIMTAL UTTARAKHAND NAINITAL BHIMTAL 263136 8006664761 DHARMRAJ03@GMAIL.COM AKHILESH KUMAR , VILLAGE - ONDA KAMLESH PRASAD , VILLAGE - ONDA DHARMRAJ PRASAD S/O INDRAJIT PRASAD ONDA BIHAR NALANDA INDIA SARE 803107 9410514430 INDRAJIT PRASAD . VILLAGE - ONDA 9410514430 9410514430

Applicant Details
Applicant's Name Date of Birth (DD/MM/YYYY) Place of Birth (Village/Town/City) District State/UT Country Gender Marital Status Citizenship of India by Employment Type Is either of your parent (in case of minor)/spouse, a government servant? Educational Qualification Are you eligible for Non-ECR category? Visible Distinguishing Mark

Family Details
Father's Name Mother's Name

Present Address Details

Residing Since(MM/YYYY) Address PIN Mobile/Tel No E-mail First Reference Name And Address Second Reference Name And Address

Permanent Address
Address PIN Mobile/Tel No

Emergency Contact Details

Name and Address Mobile/Tel No Mobile/Tel No

Other Details Self Declaration

I owe allegiance to the sovereignty, unity and integrity of India, and have not voluntarily acquired citizenship or travel document of any other country. I have not lost, surrendered or been deprived of the citizenship of India and I affirm that the information given by me in this form and the enclosures is true and I am solely responsible for its accuracy, and I am liable to be penalized or prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false information or to suppress any material information with a view to obtaining passport or travel document.
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/2

10/14/13

Application Form

Place Date

BHIMTAL 14/10/2013

https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction

2/2