Mother's name is Surname. She currently resides at the present residential address in India. Her emergency contact is Name and Address, who can be reached by mobile number or email. Previously, she has not held a diplomatic or official passport and has not previously applied for a passport that was not issued. She has never been charged with or convicted of a criminal offense in India, has never been refused a passport, and has never had her passport impounded or revoked. Additionally, she has never applied for or been granted political asylum in another country and has never returned to India on an emergency certificate or been deported. She declares allegiance to India and has not acquired citizenship in another country.

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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