GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS SUPPLEMENTARY FORM Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using blue/ black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of the application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original documents at the time of submission of the form 1. Alias Name Details (If you are also known by any other names) Surname 1.1 Alias Name1, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed) Surname 1.2 Alias Name2, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed) 2. Previous Name Details (If you have ever changed your name) Surname 2.1 Previous Name1, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed) Surname 2.2 Previous Name2, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed) Page 2 of 7 3. Previous Residence with Reference Details (Maximum two residences of longest period of stay) 3.1 Previous Residence1 - To (MM-YYYY) - From (MM-YYYY) PIN Police Station State/ UT House No. and Street Name Village or Town or City District Telephone Number Mobile Number Country First Reference Name and Address Second Reference Name and Address Telephone Number Mobile Number Page 3 of 7 3.2 Previous Residence2 - To (MM-YYYY) - From (MM-YYYY) House No. and Street Name Village or Town or City Telephone Number Mobile Number Police Station State/ UT District Country PIN Telephone Number Mobile Number First Reference Name and Address Page 4 of 7 Telephone Number Mobile Number Second Reference Name and Address Telephone Number Mobile Number House No. and Street Name Village or Town or City Police Station District 4. Permanent Residential Address (If it is different from present residential address) State/ UT Country PIN Telephone Number Mobile Number House No. and Street Name 5. Present Residential Address (If you are on a temporary visit to India) Page 5 of 7 Village or Town or City District/ County State/ Province Country PIN Telephone Number Mobile Number E-mail ID 6. Diplomatic/ Official Passport Details Place of Issue Date of Expiry (DD-MM-YYYY) Date of Issue (DD-MM-YYYY) Passport Number 7. Other Details - - - - Case/ FIR/ Warrant Number Name of Court and Place 7.1 Provide the following details if there are any criminal proceedings/ warrant pending against you and attach written permission from competent court. Page 6 of 7 Law and Section(s) 7.2 Provide details if you have ever been convicted by a Court of Law in India and attach copy of judgement Name of Court and Place Case/ FIR/ Warrant Number Law and Section(s) 7.3 Reason for refusal or denial of passport Reason for impounding/ revocation 7.4 Impounded/ Revoked Passport Details Passport Number 7.5 Name of the country if ever applied for/ been granted political asylum to/ by any foreign country 7.6 Emergency Certificate Details Page 7 of 7 8. Self Declaration I owe allegiance to the sovereignty, unity & 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. Place Date (DD-MM-YYYY) Signature/ Left Hand Thumb Impression of Applicant (If applicant is minor, either parent to sign) Date of Issue (DD-MM-YYYY) (Give MM-YYYY in case cannot recall the exact date) Reason for deportation/ repatriation Country from where deported/ repatriated Issuing Authority - - - - EC No.