2/5/2015 View/Print Submitted Form
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 15-1000315191
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name PRAGATHI MANIKANDAN
Date of Birth (DD/MM/YYYY) 29/10/2014
Place of Birth (Village/Town/City) VIRUDHACHALAM
District CUDDALORE
State/UT TAMIL NADU
Country INDIA
Gender FEMALE
Signature/Left Hand Thumb Impression
Marital Status SINGLE of Illiterate Applicant and Minors who
Citizenship of India by BIRTH cannot sign.
Employment Type NOT EMPLOYED
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 5TH PAAS OR LESS
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark A MARK ON LEFT HAND
Family Details
Father's Name MANIKANDAN NARAYANASAMY
Mother's Name VINODHA MANIKANDAN
Father/Legal guardian's File/Passport Number L1031139
Mother/Legal guardian's File/Passport Number L1021085
Present Address Details
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=15-1000315191 1/3
2/5/2015 View/Print Submitted Form
Residing Since(MM/YYYY) 10/2014
2991,L.I.G II,MMDA,MATHUR, MANALI,CHENNAI, MANALI
Address
POLICE STATION, CHENNAI SUB URBAN, TAMIL NADU
PIN 600068
Mobile/Tel No. 8608914774
E-mail [email protected]
THIYAGARAJAN,2990,L.I.G
First Reference Name And Address
II,MMDA,MATHUR,MANALI,CHENNAI-600068
Mobile/Tel No. 9940334399
Second Reference Name And Address SUMATHI,2746,'B' TYPE,MATHUR,MANALI,CHENNAI-68
Mobile/Tel No. 9962475819
Permanent Address
2991,L.I.G II,MMDA,MATHUR, MANALI,CHENNAI, MANALI
Address
POLICE STATION, CHENNAI SUB URBAN, TAMIL NADU
PIN 600068
Mobile/Tel No. 8608914774
Emergency Contact Details
MANIKANDAN,2991,L.I.G II,MMDA,MATHUR,MANALI,CHENNAI-
Name and Address
600068
Mobile/Tel No. 8608914774
E-mail [email protected]
Payment Details
Mode of Payment Online/Internet Banking
Date 05/02/2015
Receipt/Reference No. IG00OKLAD6
Amount Received (Rs.) 1000.00 (ONE THOUSAND ONLY)
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 or to suppress any material information with a view to obtaining passport or travel document.
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=15-1000315191 2/3
2/5/2015 View/Print Submitted Form
Place CHENNAI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either
Date 10/01/2015 parent to sign)
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=15-1000315191 3/3
