2/16/2021 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 21-1001183945
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name NAGA USHA DAVULURI
Date of Birth (DD/MM/YYYY) 26/01/1989
Validity Required NA
Place of Birth (Village/Town/City) CHENNAI
District CHENNAI
State/UT TAMIL NADU
Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Family Details
Father's Name SESHA KRISHNA UMASHANKAR DAVULURI
Mother's Name RAJALAKSHMI DAVULURI
Spouse's Name SHANKAR ANAND SAINATH RAO
Present Residential Address Details
NEW NO 22/10,RAJA APTS,4TH STREET POSTAL COLONY, WEST
Address
MAMBALAM, CHENNAI, TAMIL NADU
PIN 600033
Police Station R-3 ASHOKNAGAR
Mobile/Tel No. 9611981615
E-mail NAGAUSHA89@[Link]
Permanent Residential Address
NEW NO 22/10,RAJA APTS,4TH STREET POSTAL COLONY, WEST
Address
MAMBALAM, CHENNAI, TAMIL NADU
PIN 600033
Police Station R-3 ASHOKNAGAR
Mobile/Tel No. 9611981615
Emergency Contact Details
SHANKAR ANAND S,PLOT NO 3 ICF COLONY,KABILAR STREET, IAF AVADI
Name and Address
POST CHENNAI 600055
Mobile/Tel No. 9840222527
E-mail SHANKIENGG100@[Link]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number H4783913
Date of Issue 07/10/2009
Date of Expiry 06/10/2019
Place of Issue CHENNAI
File Number MASA02319809
Other Details
Enclosures
[Link] Card issued by the Income Tax Department
[Link] Card (Address Proof)
Self Declaration

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2/16/2021 Application Form
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. I have not contravened any of the conditions
relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing any
material information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my application
for an Indian passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. 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.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me in
the form is bonafide.
Place CHENNAI
Date 16/02/2021

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