2/2/2017 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 17­1001339717
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name VENKATA JAGADESH SAI DATTA NANDIKONDA
Date of Birth (DD/MM/YYYY) 27/04/1993
Validity Required NA
Place of Birth (Village/Town/City) VISAKHAPATNAM
District VISAKHAPATNAM URBAN
State/UT ANDHRA PRADESH
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN AJFPN8483L
Employment Type NOT EMPLOYED
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non­ECR category? Y
Visible Distinguishing Mark A MOLE ON THE LEFT CHEEK
Aadhaar Number 380614091803
Family Details
Father's Name SATYANARAYANA NANDIKONDA
Mother's Name ANURADHA NANDIKONDA
Present Residential Address Details
Residing Since(MM/YYYY) 07/1993
D.NO 37­3­87/2,GAJAPATHI NAGAR,KANCHARAPALEM, VISAKHAPATNAM,
Address
KANCHARA, VISAKHAPATNAM URBAN, ANDHRA PRADESH
PIN 530008
Mobile/Tel No. 9493977473
E­mail TEJASWI9SAI@GMAIL.COM
First Reference Name And Address NAMMI MALLESWARA RAO,D.NO 37­3­87/2,HAJAPATHI NAGAR,VISAKHAPATNAM
Mobile/Tel No. 7032220448
V V MURALI KRISHNA,D.NO­37­3­87 ,GAJAPATHI
Second Reference Name And Address
NAGAR,KANCHARAPALEM,VISAKHAPATNAM­08
Mobile/Tel No. 9000625565
Permanent Residential Address
D.NO 37­3­87/2,GAJAPATHI NAGAR,KANCHARAPALEM, VISAKHAPATNAM,
Address
KANCHARA, VISAKHAPATNAM URBAN, ANDHRA PRADESH
PIN 530008
Mobile/Tel No. 9493977473
Emergency Contact Details
N.SATYANARAYANA,D.NO 37­3­87/2,GAJAPATHI
Name and Address
NAGAR,KANCHARAPALEM,VISAKHAPATNAM­08
Mobile/Tel No. 9866530881
Mobile/Tel No. 9866530881
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.
Place VISAKHAPATNAM
Date 02/02/2017

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