3/22/2021 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 21-0002749352
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
HARSHKUMAR CHANDRAKANT
Applicant's Name
PATEL
Date of Birth (DD/MM/YYYY) 31/05/2000
Validity Required NA
Place of Birth (Village/Town/City) KOTHMBA
District MAHISAGAR
State/UT GUJARAT
Country INDIA Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Gender MALE cannot sign.
Marital Status SINGLE
Citizenship of India by BIRTH
PAN EOTPP1630A
Voter Id IVK2313708
Employment Type STUDENT
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark POCK MARKS ON FACE
Aadhaar Number 316790082847
Family Details
Father's Name CHANDRAKANT BHAGABHAI PATEL
Mother's Name DAKSHABEN GIRADHARBHAI PATEL
Present Residential Address Details
Address 168,FATEPURA, MAHISAGAR, GUJARAT, FATEPURA,
MAHISAGAR, GUJARAT
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3/22/2021 View/Print Submitted Form
PIN 389230
Police Station KOTHAMBA
Mobile/Tel No. 6354080778
E-mail HCP855@[Link]
Permanent Residential Address
168,FATEPURA, MAHISAGAR, GUJARAT, FATEPURA,
Address
MAHISAGAR, GUJARAT
PIN 389230
Police Station KOTHAMBA
Mobile/Tel No. 6354080778
Emergency Contact Details
Name and Address CHANDRAKANT PATEL , FATEPURA
Mobile/Tel No. 9879990855
E-mail CBP855@[Link]
Other Details
Payment Details
Mode of Payment Online/Internet Banking
Date 22/03/2021
Receipt/Reference No. IGAKUGZZB7
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
[Link] Card/E-Aadhaar
[Link] Card (Address Proof)
Self Declaration
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 FATEPURA Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 21/03/2021 to sign)
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