Vous êtes sur la page 1sur 2

File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS

PASSPORT APPLICATION 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.

Service Required
Application Reference Number 17-1009878445

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name BIJOY MAJUMDER

Date of Birth (DD/MM/YYYY) 02/01/1955

Validity Required NA

Place of Birth (Village/Town/City) KOLKATA

District NORTH 24 PARGANAS

State/UT WEST BENGAL

Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.

Citizenship of India by BIRTH

PAN ADMPM3461C

Voter Id WB20134687655

Employment Type RETIRED

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Visible Distinguishing Mark MARK IN LEFT CHEST

Aadhaar Number 667661188448

Family Details
Father's Name LATE DURGA NATH MAJUMDER

Mother's Name ARUNA MAJUMDER

Spouse's Name SHIBANI MAJUMDER


Present Residential Address Details
Residing Since(MM/YYYY) 09/1991
Address 109/01, CO-OPRATIVE COLONY, RAHARA, KHARDA PS,
BARRACKPORE, WEST BENGAL

PIN 700118

Mobile/Tel No. 9433889134

E-mail MAIL.VIDYUT@GMAIL.COM

BIDYUT ROY, 151/11/1, CO-OPRATIVE COLONY, KOLKATA


First Reference Name And Address
700118

Mobile/Tel No. 9433429358

SOUMYA MAJUMDAR, 109/1, CO-OPRATIVE COLONY,


Second Reference Name And Address
KOLKATA 700118

Mobile/Tel No. 9903862171


Permanent Residential Address
109/01, CO-OPRATIVE COLONY, RAHARA, KHARDA PS,
Address
BARRACKPORE, WEST BENGAL

PIN 700118

Mobile/Tel No. 9433889134


Emergency Contact Details
Name and Address BIDYUT ROY

Mobile/Tel No. 9433429358

E-mail MAIL.VIDYUT@GMAIL.COM
Payment Details
Mode of Payment Debit/Credit Card

Date 10/10/2017

Receipt/Reference No. CPB1284719

1350.00 (ONE THOUSAND THREE HUNDRED AND FIFTY


Amount Received (Rs.)
ONLY)
Enclosures
1. 6.

2. 7.

3. 8.

4. 9.

5. 10.
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.

Place KOLKATA Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 10/10/2017 to sign)