sample passport application form
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7/27/2019 sample passport application form
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23/10/13 9:28 PMApplication Form
Page 1 of 2https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction
PASSPORT APPLICATION FORM
Government of INDIA,Ministry of External Affairs
Service Required
Application Reference Number 13-0011996166
Applying For FRESH
Type of Application NORMALType of Passport Booklet NORMAL
Applicant Details
Applicant's Name DEVANSH SINGH PATHANIA
Date of Birth (DD/MM/YYYY) 19/06/1992
Place of Birth (Village/Town/City) NEW DELHI
District SOUTH DELHI
State/UT DELHI
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN BOBPP4248FVoter Id SJE1495349
Employment Type STUDENT
Is either of your parent (in case of minor)/spouse, agovernment servant?
Y
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark CUT MARK ON RIGHT EYEBROW
Aadhaar Number 780771283649
Family Details
Father's Name DES RAJ PATHANIA
Mother's Name PARVEEN PATHANIA
Present Address DetailsResiding Since(MM/YYYY) 05/2009
Address1655,LAXMI BAI NAGAR NEW DELHI DELHI SOUTH DELHISAROJINI NAGAR
PIN 110023
Mobile/Tel No 9711706618 / 01124107689
E-mail [email protected]
First Reference Name And Address K.S SUBHALAXMI 1657 LAMI BAI NAGAR NEW DELHI 110023
Mobile/Tel No 9560387698
Second Reference Name And Address KISHAN LAL D-112 SAROJNI NAGAR NEW DELHI 110023
Mobile/Tel No 9582507812
Permanent Address
Address 1655,LAXMI BAI NAGAR NEW DELHI DELHI SOUTH DELHISAROJINI NAGAR
PIN 110023
Mobile/Tel No 9711706618 / 01124107689
Emergency Contact Details
Name and AddressDES RAJ PATHANIA ,1655 LAXMI BAI NAGAR NEW DELHI110023
Mobile/Tel No 9868537012
Mobile/Tel No 9868537012
Other Details
Self Declaration
I owe allegiance to the sovereignty, unity and integrity of India, and have not voluntarily acquired citizenship or travel document ofany other country. I have not lost, surrendered or been deprived of the citizenship of India and I affirm that the information given byme in this form and the enclosures is true and I am solely responsible for its accuracy, and I am liable to be penalized or
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7/27/2019 sample passport application form
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23/10/13 9:28 PMApplication Form
Page 2 of 2https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction
prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any falseinformation or to suppress any material information with a view to obtaining passport or travel document.
Place NEW DELHI
Date 23/10/2013