- The document is a passport application form from the Government of India that contains fields for applicant information such as name, date of birth, address, citizenship status, and employment. - It requests information on any previous passports or applications and whether the applicant has ever been convicted of a crime or denied a passport. - The applicant must declare allegiance to India and affirm that all information provided is true under the penalty of perjury as outlined in the Passports Act of 1967.

1. PASSPORT APPLICATION FORM
Government of India, Ministry of External Affairs
Please read the Passport Instruction Booklet carefully before filling the form. Furnishing of incorrect informationl
suppression of information would lead to rejection of 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. All fields
marked with (.) are mandatory to fill.
Type of Application '* 0Normal OTatkaal
Type of Passport Booklet '* 036 Pages (960 Pages
Validity Required (For minors between 15 and 18) 010 years OUp to age 18 €)Not Applicable
Applicant's Given Name (Given Name means First Name followed by middle Name (if any)) '*
Surname
Are you known by any other names(aliases)? '* o Yes (9No
Have you ever changed your name? * OYes eNo
Date of Birth (OO/MMNYVY) *
Country (If abroad)*
State (If in India)* District (If in India)*
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If born before 15/08/1947 in a place now in Pakistan or Bangladesh, select "Undivided India",
Gender * IFI=M. AI- E IMarital Status * 1M A-'R R ~ Citizenship of India by
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PAN (If available) IA"X.::r P B> It 5"0'3 .B I Voter ID (If available) IW 8/' g /11 2.. / J.f rIT- 2 "J-I!i
Employment Type *
Is either of your parent (in case of minor)/ spouse, a government servant? * I NO
Educational Qualification * FL"D I
1- l<ErH 127<. SGCON.t:>I'- R.'-{ Are you eligible for Non~ECR category? *
Father's Given Name (Given Name means First Name followed by Middle Name (If any))
Surname
Legal Guardian's Given Name (if applicable)
Surname
Mother's Given Name (Given Name means First Name followed by Middle Name (If any))
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2. Surname
Is your present address out of India? * o Yes 0No
Is permanent address same as present address? * 0Yes ONo
Name and Address *
Mobile Number Telephone Number 103.3 - 2-;1/-0 2- ,- 2 It- 3 q I
E-maillD
Have you heidi hold any diplomaticl official passport?
Passport Number Date of Issue(DD/MMNYVY) Nt l ­
Date of Expiry (DD/MMNYYY)
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IN 0" A p.p L c;>! S i- J;' I
Place of Issue
Have you ever applied for passport, but not issued? * 0 Yes (9 No
1) Have you ever been charged with criminal proceedings or any arrest warrant! summon pending OYes (0No
before a court of India? *
2) Have you at any time during the period of 5 years immediately preceding the date of this application OYes eNo
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? * OYes 0No
4) Has your Passport ever been impounded or Revoked? * OYes eNo
5) Have you ever applied fori been granted political asylum tol by any foreign country? * OYes 9No
6) Have you ever returned to India on Emergency Certificate (EC) or were ever deported or repatriated? * OYes eNo
Self Declaration
lowe 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 ofthe 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 of.travel document.
o I Agree ~ "P"'-C.. ~"'-¥ J...eA-- .
Date (DD/MM/YYVY)
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