This document is a surrender certificate application form for surrendering an Indian passport after acquiring foreign nationality or renouncing Indian citizenship. It requests passport details like number, date of issue, and place of issue. It also requests details about the applicant like name, date of birth, place of birth, gender, address, nationality being acquired, and date of acquiring foreign nationality. The applicant must declare that the information provided is true and accurate, and acknowledge legal penalties for providing false information to the passport authority.