View/Print Submitted Form 13/12/23, 1:53 PM
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 23-1015232401
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name DEVAIAH KUPPANDA SUBBAIAH
GLENN DEVAIAH KUPPANDA
Alias Name1
SUBBAIAH
Date of Birth (DD/MM/YYYY) 20/10/2003
Validity Required NA
Place of Birth (Village/Town/City) MYSURU
District MYSURU CITY
State/UT KARNATAKA Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN OVAPS0467Q
Voter Id SLC5221783
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 SCAR ON RIGHT HIP
Aadhaar Number 981447971979
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View/Print Submitted Form 13/12/23, 1:53 PM
Family Details
Father's Name LATE SUBBAIAH KUPPANDA GANAPATHI
Mother's Name NAMITHA KUPPANDA SUBBAIAH
Present Residential Address Details
981/1,9TH MAIN,1ST CROSS, MYSORE, MYSURU CITY,
Address
KARNATAKA
PIN 570023
Police Station KUVEMPUNAGARA
Mobile/Tel No. 8762110544 / 8762110544
E-mail GLENNDEVAIAH24@[Link]
Emergency Contact Details
Name and Address SHREYA CHONDAMMA K S
Mobile/Tel No. 7899923849 / 7899923849
E-mail SHREYASUBBAIAH@[Link]
Other Details
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
[Link] License issued by the Transport department of concerned state Government
[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 MYSURU Signature/Left Hand Thumb Impression of
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View/Print Submitted Form 13/12/23, 1:53 PM
Applicant (If applicant is minor, either parent
Date 13/12/2023 to sign)
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