7/22/13

Application Form

PASSPORTAPPLICATIONFORM
GovernmentofINDIA,MinistryofExternalAffairs
ServiceRequired
ApplicationReferenceNumber
ApplyingFor
IfReissue,specifyreason(s)
TypeofApplication
TypeofPassportBooklet
ApplicantDetails
Applicant'sName
DateofBirth(DD/MM/YYYY)
PlaceofBirth(Village/Town/City)
District
State/UT
Country
Gender
MaritalStatus
CitizenshipofIndiaby
VoterID
EmploymentType
Iseitherofyourparent(incaseofminor)/spouse,a
governmentservant?
EducationalQualification
AreyoueligibleforNonECRcategory?
AadhaarNumber
FamilyDetails
Father'sName
Mother'sName
Spouse'sName
PresentAddressDetails
ResidingSince(MM/YYYY)
Address
PIN
Mobile/TelNo
Email
FirstReferenceNameAndAddress
Mobile/TelNo
SecondReferenceNameAndAddress
Mobile/TelNo
PermanentAddress
Address
PIN
Mobile/TelNo
EmergencyContactDetails
NameandAddress

130008812762
REISSUE
VALIDITYEXPIREDWITHIN3YEARS/DUETOEXPIRE.
NORMAL
NORMAL
RAJIVKUMARMAHESHWARI
15/08/1964
ETAWA
ETAWAH
UTTARPRADESH
INDIA
MALE
MARRIED
BIRTH
HCN0882779
SELFEMPLOYED
N
10THPASSANDABOVE
Y
502936226143
RATANPRAKASHMAHESHWARI
SAVITAMAHESHWARI
SEEMAMAHESHWARI
10/1994
52/3B772CHURCHROADJAWALANAGARSHAHDARADELHI
EASTDELHIVIVEKVIHAR
110032
9811810777/01122380777
ARPIT.ABC@GMAIL.COM
HIMANSHUSINGHAL3/108NEHRUGALIVISHWASNAGAR
SHAHDARADELHI110032
9999466669
ANKITSINGHAL3/108NEHRUGALIVISHWASNAGARSHAHDARA
DELHI110032
9999888388
52/3B772CHURCHROADJAWALANAGARSHAHDARADELHI
EASTDELHIVIVEKVIHAR
110032
9811810777/01122380777
DINESHSINGHAL3/108NEHRUGALIVISHWASNAGAR
SHAHDARADELHI110032
9212070666
9212070666

Mobile/TelNo
Mobile/TelNo
PreviousPassport/ApplicationDetails
Detailsoflatestheld/existing/lost/damagedOrdinaryPassport
PassportNumber
E3267726
DateofIssue
28/11/2002
DateofExpiry
27/11/2012
PlaceofIssue
DELHI
OtherDetails
SelfDeclaration
Ioweallegiancetothesovereignty,unityandintegrityofIndia,andhavenotvoluntarilyacquiredcitizenshiportravel
documentofanyothercountry.Ihavenotlost,surrenderedorbeendeprivedofthecitizenshipofIndiaandIaffirmthatthe
informationgivenbymeinthisformandtheenclosuresistrueandIamsolelyresponsibleforitsaccuracy,andIamliable
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction

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7/22/13

Application Form

tobepenalizedorprosecutediffoundotherwise.IamawarethatunderthePassportsAct,1967itisacriminaloffenceto
furnishanyfalseinformationortosuppressanymaterialinformationwithaviewtoobtainingpassportortraveldocument.
Place
DELHI
Date
22/07/2013

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

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