1. File Number (For Office Use Only)
(TextField1)
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.
1. Service Required
Please paste your
unsigned recent colour
photograph with white
background of size
4.5cm X 3.5cm. [Not
needed for applicants
submitting the
application at Passport
Seva Kendra]
1.1 Applying for
Fresh Passport
(Fresh Passport) Unchecked
Re-issue of Passport
(Re-issue of Passport) Checked
1.2 If re-issue, specify reason(s)
Validity Expired within 3 years/ Due to Expire
(Validity Expired within 3 years/ Due to Expire) Unchecked
Exhaustion of Pages
(Exhaustion of Pages) Unchecked
Validity Expired more than 3 years ago
(Validity Expired more than 3 years ago) Unchecked
Lost Passport
(Lost Passport) Unchecked
Change in Existing Personal Particulars
(Change in Existing Personal Particulars) Checked
Damaged Passport

2. (Damaged Passport) Unchecked
1.3 If change in existing personal particulars, specify reason(s)
Appearance
(Appearance) Unchecked
Signature
(Signature) Unchecked
Given Name
(Given Name) Unchecked
Surname
(Surname) Unchecked
Date of Birth
(Date of Birth) Unchecked
Spouse Name
(Spouse Name) Unchecked
Address
(Address) Checked
Delete ECR
(Delete ECR) Unchecked
Others, Please specify
(Others, Please specify) Unchecked
(TextField2) FLATNO1701ODYSSEYIIORCH
Signature/ Left Hand Thumb
Impression of Illiterate
Applicant and Minors who
cannot sign.
(TextField2) ARDAVHIRANANDANIGDNS
1.4 Type of Application
Normal
(Normal) Unchecked
Tatkaal
(Tatkaal) Checked
1.5 Type of Passport Booklet
36 Pages
(36 Pages) Checked

3. 60 Pages
(60 Pages) Unchecked
1.6 Validity Required
10 Years
(10 Years) Unchecked
Up to age 18
(Up to age 18) Unchecked
(For minors between 15 and 18 years)
2. Applicant Details
(2.1 Applicant's Given Name (Given Name means First name followed by Middle name
(If any))(Initials not allowed)) BRINDALAKSHMY
(TextField4)
(Surname) RAMKRISHNAN
(TextField3)
2.2 Are you known by any other names (aliases)?
Yes
(Yes) Checked
No
(No) Unchecked
If yes, provide details in Column 1 of Supplementary Form
2.3 Have you ever changed your name?
Yes
(Yes) Unchecked
No
(No) Unchecked
If yes, provide details in Column 2 of Supplementary Form
Page 1 of 6

4. (TextField4) 18
(TextField4) 08
(TextField4) 1963
2.4 Date of Birth (DD-MM-YYYY)
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(2.5 Place of Birth (Village or Town or City)) CHEMBUR MUMBAI
(District (If born in India)) MUMBAI
(State/ UT (If born in India)) MAHARASHTRA
Country (If born abroad) If born before 15/08/1947 in a place now in Pakistan or
Bangladesh, write
"Undivided India"
(TextField3)
Male
(Male) Unchecked
Female
(Female) Checked
2.6 Gender
2.7 Marital Status
Single
(Single) Unchecked
Married
(Married) Checked
Divorced
(Divorced) Unchecked
Widow/ Widower
(Widow/ Widower) Unchecked
Separated
(Separated) Unchecked
Birth
(Birth) Checked
Descent
(Descent) Unchecked
Registration/ Naturalization
(Registration/ Naturalization) Unchecked

5. 2.8 Citizenship of India by
(2.9 PAN (If available)) AGYPR6592C
(2.10 Voter ID (If available)) 168/35/1052/08
2.11 Employment Type
PSU
(PSU) Unchecked
Government
(Government) Unchecked
Statutory Body
(Statutory Body) Unchecked
Retired Government Servant
(Retired Government Servant) Unchecked
Self Employed
(Self Employed) Unchecked
Private
(Private) Unchecked
Homemaker
(Homemaker) Checked
Not Employed
(Not Employed) Unchecked
Retired-Private Service
(Retired-Private Service) Unchecked
Student
(Student) Unchecked
Others
(Others) Unchecked
Owners, Partners & Directors of companies which are members of CII, FICCI &
ASSOCHAM
(Owners, Partners & Directors of companies which are members of CII, FICCI &
ASSOCHAM) Unchecked
(2.12 If employed in Government/ Statutory Body/ PSU, specify organization name)
(TextField4)
2.13 Is either of your parent (in case of minor)/ spouse, a government servant?
Yes

6. (Yes) Unchecked
No
(No) Checked
2.14 Educational Qualification
5th pass or less
(5th pass or less) Unchecked
Between 6th and 9th Standard
(Between 6th and 9th Standard) Unchecked
10th pass and above
(10th pass and above) Unchecked
Graduate and above
(Graduate and above) Checked
2.15 Are you eligible for Non-ECR category?
Yes
(Yes) Checked
No
(No) Unchecked
For details, see Column 2.15, section B of
Instruction Booklet
(2.16 Visible Distinguishing Mark) MOLE ON THE BASE OF RIGHT EAR
(TextField4)
2.17 Aadhaar Number
(TextField4) 435341128048
3. Family Details
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7. (3.1 Father's Given Name (Given Name means First name followed by Middle name
(If any)) (Initials not allowed)) PARUR KRISHNA YEGNA NARAYANA
(TextField4)
(Surname) IYER
(TextField3)
(3.2 Mother's Given Name (Given Name means First name followed by Middle name
(If any)) (Initials not allowed)) KAMALA
(TextField4)
(Surname) YEGNA NARAYANA
(TextField3) IYER
(3.3 Legal Guardian's Given Name (If applicable) (Initials not allowed))
(TextField4)
(Surname)
(TextField3)
3.4 Spouse's Given Name (Given Name means First name followed by Middle name (If
any)) (Initials not allowed)
(TextField3) RAMKRISHNAN
(TextField4)
(Surname) BALASUBRAMANIAN
(TextField3)
3.5 If applicant is minor, provide following details
Parent's Passport Details
(If passport has been applied for but not received, give File Number)
(Father/ Legal Guardian's File/ Passport Number)
(Father/ Legal Guardian's Nationality, if not Indian)
(Mother/ Legal Guardian's File/ Passport Number)
(Mother/ Legal Guardian's Nationality, if not Indian)
4. Present Residential Address Details (Where applicant presently resides)
4.1 Residing Since (MM-YYYY)
If you have been residing at your present residential address for less than
one year, mention the previous address(es) in Column 3 of SupplementaryForm. If
you are on a temporary visit to India, fill Column 5 of
Supplementary Form.
(TextField4) 10
(TextField4) 2011
-
Page 3 of 6

8. (4.2 House No. and Street Name) 1701 ODYSSEY II ORCHARAD AV
(TextField4)
(Village or Town or City) HIRANADANI GDNS POWAI
(District) MUMBAI
(Police Station) POWAI
(State/ UT) MAHRASHTRA
(PIN) 400076
(Mobile Number) 9967636302
(Telephone Number) 25700029
(E-mail ID) brindaiyer@hotmail.com
(TextField4)
4.3 Is permanent address same as present address?
No
(No) Unchecked
If no, provide details in Column 4
of Supplementary Form
Yes
(Yes) Checked
5. Emergency Contact Details
(Name and Address (Mention address only if different from present residential
address))
(TextField3)
(TextField3)
(TextField4)
(Mobile Number)
(Telephone Number)
(E-mail ID)
(TextField4)
Page 4 of 6

9. 6. References in your Village or Town or City
(6.1 First Reference Name and Address) MRS KAMALA Y N IYER FLATNO 601
(TextField3) MAHESH KUTIR 14TH ROAD CHEMBUR
(TextField3) MUMBAI 400071
(TextField4)
Mobile Number
Telephone Number
(TextField4) 9324214319
(TextField4) 25212480
(6.2 Second Reference Name and Address) MRS SAPNA BAJAJ FLAT NO 102
(TextField3) SOLITAIRE ORCHARD AV HIRANANDAN
(TextField3) I GDNS POWAI MUMBAI 400076
(TextField4)
Mobile Number
Telephone Number
(TextField4) 9833032220
(TextField4) 25797810
7. Previous Passport/ Application Details
7.1 Details of latest held/ existing/ lost/ damaged ordinary passport
Passport Number
Date of Issue (DD-MM-YYYY)
Date of Expiry (DD-MM-YYYY)
(TextField4) G7369740
(TextField4) 18
(TextField4) 01
(TextField4) 2008
(TextField4) 17
(TextField4) 01
(TextField4) 2018
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Place of Issue
(TextField3) MUMBAI
If you have held/ hold any diplomatic/ official passport, provide details in
Column 6 of Supplementary Form
7.2 Have you ever applied for passport, but not issued?
No

10. (No) Checked
If yes, provide the following
details
Yes
(Yes) Unchecked
File Number
Month and Year of applying
(TextField3)
(TextField4)
(TextField4)
-
Name of passport office where applied
(TextField3)
8. Other details
8.1 Have you ever been charged with criminal proceedings or any arrest warrant/
summon
pending before a court in India?
If yes, fill Column 7.1 of Supplementary Form
No
(No) Checked
Yes
(Yes) Unchecked
Page 5 of 6

11. 8.2 Have you at any time during the period of 5 years immediately preceding the
date of
this application been convicted by a court in India for any criminal offence &
sentenced
to imprisonment for two years or more?
If yes, fill Column 7.2 of Supplementary Form
No
(No) Checked
Yes
(Yes) Unchecked
8.3 Have you ever been refused or denied passport?
If yes, give reason for refusal or denial of Passport in Column 7.3 of
Supplementary
Form
No
(No) Checked
Yes
(Yes) Unchecked
8.4 Has your Passport ever been Impounded or Revoked?
If yes, provide details in Column 7.4 of Supplementary Form
No
(No) Checked
Yes
(Yes) Unchecked
8.5 Have you ever applied for/ been granted political asylum to/ by any foreign
country?
If yes, provide details in Column 7.5 of Supplementary Form
No
(No) Checked
Yes
(Yes) Unchecked
8.6 Have you ever returned to India on Emergency Certificate (EC) or were ever
deported
or repatriated?
If yes, provide details in Column 7.6 of Supplementary Form
No
(No) Checked
Yes

12. (Yes) Unchecked
9. Fee Details (Not to be filled by applicants submitting the application at
Passport Seva Kendra)
9.1 Fee amount in (Rs)
9.2 If paid by Demand Draft (DD), provide the following details
(TextField4)
DD Number
(TextField4)
DD Issue Date
DD Expiry Date
(TextField4)
(TextField4)
(TextField4)
(TextField4)
(TextField4)
(TextField4)
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Bank Name
(TextField4)
Branch
(TextField4)
10. Enclosures
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
11. Self Declaration

13. 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 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) MUMBAI
Signature/ Left Hand
Thumb Impression of
Applicant (If applicant is
minor, either parent to
sign)
Date (DD-MM-YYYY)
(TextField4) 28
(TextField4) 05
(TextField4) 2014
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Page 6 of 6