9/20/2016
View/PrintSubmittedForm
FileNumber(ForOfficeUseOnly)
GOVERNMENTOFINDIA,MINISTRYOFEXTERNALAFFAIRS
PASSPORTAPPLICATIONFORM
Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/blackinkballpointpenonly.Furnishingofincorrectinformation/suppressionofinformationwouldleadtorejectionof
the application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your
originaldocumentsatthetimeofsubmissionoftheform.
ServiceRequired
ApplicationReferenceNumber
161007986357
ApplyingFor
FRESH
TypeofApplication
NORMAL
TypeofPassportBooklet
JUMBO
ApplicantDetails
Applicant'sName
GOWSHIKAVERIPOYYAMOZHI
DateofBirth(DD/MM/YYYY)
29/03/1993
ValidityRequired
NA
PlaceofBirth(Village/Town/City)
MADURAI
District
MADURAICITY
State/UT
TAMILNADU
Country
INDIA
Gender
FEMALE
MaritalStatus
SINGLE
CitizenshipofIndiaby
BIRTH
PAN
BRPPG0482H
EmploymentType
HOMEMAKER
Iseitherofyourparent(incaseof
minor)/spouse,agovernmentservant?
EducationalQualification
GRADUATEANDABOVE
Signature/LeftHandThumbImpression
ofIlliterateApplicantandMinorswho
cannotsign.
AreyoueligibleforNonECRcategory? Y
VisibleDistinguishingMark
AMOLEINRIGHTHAND
AadhaarNumber
949126320169
FamilyDetails
Father'sName
POYYAMOZHIK
Mother'sName
SHANTHIP
PresentResidentialAddressDetails
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ResidingSince(MM/YYYY)
03/1993
Address
26,KANNAKUPILLAISTREET,,AVANIYAPURAM,
AVANIAPURAM,MADURAICITY,TAMILNADU
PIN
625012
Mobile/TelNo.
9677541141/04522672323
Email
[email protected]
FirstReferenceNameAndAddress
PRETHIVEENO27,KANAKUPILLAI
STREET,AVNIYAPURAM,MADURAI625012
Mobile/TelNo.
9943320808
SecondReferenceNameAndAddress
RAVI13B,KANAKUPILLAI
STREET,AVNIYAPURAM,MADURAI625012
Mobile/TelNo.
9751648608
PermanentResidentialAddress
Address
26,KANNAKUPILLAISTREET,,AVANIYAPURAM,
AVANIAPURAM,MADURAICITY,TAMILNADU
PIN
625012
Mobile/TelNo.
9677541141/04522672323
EmergencyContactDetails
NameandAddress
SHANTHI.P
Mobile/TelNo.
9487143933/04522672323
Email
[email protected]
FeeDetails(NottobefilledbyapplicantssubmittingtheapplicationatPassportSevaKendra/PassportOffice)
Feeamountin(Rs)
IfpaidbyDemandDraft(DD),providethefollowingdetails
DDIssueDate(dd/mm/yyyy)
DDExpiryDate(dd/mm/yyyy)
BankName
Branch
Enclosures
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
SelfDeclaration
Ioweallegiancetothesovereignty,unityandintegrityofIndia,andhavenotvoluntarilyacquiredcitizenshiportraveldocument
ofanyothercountry.Ihavenotlost,surrenderedorbeendeprivedofthecitizenshipofIndiaandIaffirmthattheinformationgiven
bymeinthisformandtheenclosuresistrueandIamsolelyresponsibleforitsaccuracy,andIamliabletobepenalizedor
prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false
informationortosuppressanymaterialinformationwithaviewtoobtainingpassportortraveldocument.
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Place
MADURAI
Date
08/09/2016
Signature/LeftHandThumbImpressionof
Applicant(Ifapplicantisminor,either
parenttosign)
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