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FileNumber(ForOfficeUseOnly)

GOVERNMENTOFINDIA,MINISTRYOFEXTERNALAFFAIRS

PASSPORTAPPLICATIONFORM

Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/blackinkballpointpenonly.Furnishingofincorrectinformation/suppressionofinformationwouldleadtorejectionof
the application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your
originaldocumentsatthetimeofsubmissionoftheform.

ServiceRequired
ApplicationReferenceNumber

141008574365

ApplyingFor

FRESH

TypeofApplication

NORMAL

TypeofPassportBooklet

NORMAL

ValidityRequired

NA

ApplicantDetails
Applicant'sName

ANILCHANDRADAS

DateofBirth(DD/MM/YYYY)

07/12/1965

PlaceofBirth(Village/Town/City)

KOLKATA

District

NORTH24PARGANAS

State/UT

WESTBENGAL

Country

INDIA

Gender

MALE

MaritalStatus

MARRIED

CitizenshipofIndiaby

BIRTH

PAN

AEXPD0423R

VoterId

KTF2747798

EmploymentType

PRIVATE

Iseitherofyourparent(incaseof
minor)/spouse,agovernmentservant?

EducationalQualification

10THPASSANDABOVE

Signature/LeftHandThumbImpression
ofIlliterateApplicantandMinorswho
cannotsign.

AreyoueligibleforNonECRcategory? Y
VisibleDistinguishingMark

ACUTINTHERIGHTEYESIDE

FamilyDetails
Father'sName

NIRMALCHANDRADAS

Mother'sName

SOVARANIDAS

Spouse'sName

SWAPNADAS

PresentAddressDetails
ResidingSince(MM/YYYY)

07/1968

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=141008574365

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Address

88PRANKRISHNASAHALANE,BARANAGAR,KOLKATA,
BARANAGARPS,BARRACKPORE,WESTBENGAL

PIN

700036

Mobile/TelNo.

9002105598

Email

ANILCHANDRADAS1965@GMAIL.COM

FirstReferenceNameAndAddress

SUSHILCHANDRADAS,HALDIAPETROCHEMICALS
LIMITED,DURGACHOWK,HALDIA

Mobile/TelNo.

9434017061

SecondReferenceNameAndAddress

TAPANROY,4KNATURALVIEW,82ULTADANGAMAIN
ROAD,KOLKATA700067

Mobile/TelNo.

8274974811

PermanentAddress
Address

88PRANKRISHNASAHALANE,BARANAGAR,KOLKATA,
BARANAGARPS,BARRACKPORE,WESTBENGAL

PIN

700036

Mobile/TelNo.

9002105598

EmergencyContactDetails
NameandAddress

SWAPNADAS,88PRANKRISHNASAHALANE,
BARANAGAR,KOLKATA700036

Mobile/TelNo.

9903958943/03325775891

Ifyouhaveheld/holdanydiplomatic/officialpassport,providedetails
PassportNumber

A6264613

DateofIssue

09/10/1998

DateofExpiry

08/10/2008

PlaceofIssue

CALCUTTA

PaymentDetails
ModeofPayment

Challan

Date

14/10/2014

Receipt/ReferenceNo.

5979084

AmountReceived(Rs.)

1500.00(ONETHOUSANDFIVEHUNDREDONLY)

Enclosures
1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

SelfDeclaration
Ioweallegiancetothesovereignty,unityandintegrityofIndia,andhavenotvoluntarilyacquiredcitizenshiportraveldocument
ofanyothercountry.Ihavenotlost,surrenderedorbeendeprivedofthecitizenshipofIndiaandIaffirmthattheinformationgiven
bymeinthisformandtheenclosuresistrueandIamsolelyresponsibleforitsaccuracy,andIamliabletobepenalizedor
prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false
informationortosuppressanymaterialinformationwithaviewtoobtainingpassportortraveldocument.

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Place

KOLKATA

Date

12/10/2014

Signature/LeftHandThumbImpressionof
Applicant(Ifapplicantisminor,either
parenttosign)

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