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File Number (For Office Use Only)
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.
Service Required
Application Reference Number
16-0005506514
Applying For
FRESH
Type of Application
TATKAAL
Type of Passport Booklet
NORMAL
Applicant Details
Applicant's Name
VANSHITA
Date of Birth (DD/MM/YYYY)
07/02/2006
Validity Required
NA
Place of Birth (Village/Town/City)
PATTI
District
TARN TARAN
State/UT
PUNJAB
Country
INDIA
Gender
FEMALE
Marital Status
SINGLE
Citizenship of India by
BIRTH
Employment Type
STUDENT
Is either of your parent (in case of
minor)/spouse, a government servant?
Educational Qualification
BETWEEN 6TH AND 9TH STANDARD
Are you eligible for Non-ECR category?
Visible Distinguishing Mark
NO
Aadhaar Number
461625717158
Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
cannot sign.
Family Details
1 of 3
Father's Name
RAMESH KUMAR
Mother's Name
NAGINA RANI
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Present Residential Address Details
Residing Since(MM/YYYY)
02/2006
Address
675/9 NEAR KATLUI MANDIR WARD NO -9, PATTI, PATTI,
TARN TARAN, PUNJAB
PIN
143401
Mobile/Tel No.
9914641222
E-mail
[email protected]
First Reference Name And Address
LALIT KUMAR NEAR KATLUI MANDIR WARD NO-9 , PATTI
Mobile/Tel No.
7837374040
Second Reference Name And Address
RAJINDER KUMAR NEAR KATLUI MANDIR WARD NO -9
PATTI
Mobile/Tel No.
9814795858
Permanent Residential Address
Address
675/9 NEAR KATLUI MANDIR WARD NO -9, PATTI, PATTI,
TARN TARAN, PUNJAB
PIN
143401
Mobile/Tel No.
9914641222
Emergency Contact Details
Name and Address
RAMESH KUMAR
Mobile/Tel No.
9914641222
Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)
Fee amount in (Rs)
If paid by Demand Draft(DD), provide the following details
DD Issue Date (dd/mm/yyyy)
DD Expiry Date (dd/mm/yyyy)
Bank Name
Branch
Enclosures
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
Self Declaration
I owe allegiance to the sovereignty, unity and 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
2 of 3
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or to suppress any material information with a view to obtaining passport or travel document.
3 of 3
Place
AMRITSAR
Date
05/05/2016
Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
to sign)
05/05/2016 07:29 PM
