1. Mother's Given Name (Given Name means First Name followed by Middle Name (If any))
Surname
Present Residential Address Details (where applicant presently resides)
Is your present address out of India? * O^es @No
Is permanent address same as present address? * Q ^ e s O^o
Emergency Contact Details *
Name and Address
Mobile Number
E-mail ID
cftrtU7-/?3 Telephone Number
J#7je/- moras(Dycthoo' ?r
Previous Passport/ Application Details
Have you held/ hold any diplomatic/ official passport? * Q Yes (gf No
Have you ever applied for passport, but not issued? * Q Yes @HMo
Other Details
1) Have you ever been charged with criminal proceedings or any arrest warrant/ summon pending QYes ($Uo
before a court of India? *
2) Have you at any time during the period of 5 years immediately preceding the date of this application QYes (gfNo
been convicted by a court in India for any criminal offence and sentenced to imprisonment for two
years or more? *
3) Have you ever been refused or denied passport? * O^es Qjfio
4) Has your Passport ever been impounded or Revoked? * O^es Qffio
5) Have you ever applied for/ been granted political asylum to/ by any foreign country? * O^es @fJo
6) Have you ever returned to India on Emergency Certificate (EC) or were ever deported or repatriated? * QYes (gfN'o
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 the citizenship of India and I affirm that the information given by me in
this form and the enclosures is true and I solely responsible for its accuracy, and I am liable to be penalized or prosecuted if found
otherwise. I am aware that under the Passport 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.
0^1 Agree
Place * Date (DD/MM/YYYY) * 15/04/2014
VALIDATE & SAVE
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