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8/6/2018 View/Print Submitted Form

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 18-1007875207

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name GIRIJA KONERU

Date of Birth (DD/MM/YYYY) 12/10/1996

Validity Required NA

Place of Birth (Village/Town/City) SRIKAKULAM

District SRIKAKULAM

State/UT ANDHRA PRADESH

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

Citizenship of India by BIRTH

Employment Type NOT EMPLOYED

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 684033335873

Family Details
Father's Name JOGARAO KONERU

Mother's Name BANUMATI KONERU


Present Residential Address Details
1-160, CHINNA VEEDHI, VAJRAPU KOTTURU, M GADURU,
Address
SRIKAKULAM RURAL, SRIKAKULAM, ANDHRA PRADESH

PIN 532219

Mobile/Tel No. 8790546442

E-mail NARU.V@YAHOO.COM
Emergency Contact Details
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=18-1007875207 1/2
8/6/2018 View/Print Submitted Form

Name and Address KONERU BHANUMATI

Mobile/Tel No. 7330709449


Payment Details
Mode of Payment Debit/Credit Card

Date 06/08/2018

Receipt/Reference No. CPJ1262835

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)


Enclosures
1.Aadhaar Card/E-Aadhaar

2.Aadhaar Card
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 SRIKAKULAM Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 06/08/2018 to sign)

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