2/3/25, 9:01 AM 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 25-0001272900
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name YASH KADAM
Date of Birth (DD/MM/YYYY) 20/07/2002
Validity Required NA
Place of Birth (Village/Town/City) DAHISAR
District MUMBAI
State/UT MAHARASHTRA
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status SINGLE cannot sign.
Citizenship of India by BIRTH
PAN KBLPK9642E
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 BIRTH MARK ON RIGHT HAND WRIST
Aadhaar Number 957072151291
Family Details
Father's Name AVINASH KADAM
Mother's Name APARNA KADAM
Present Residential Address Details
BS DUBE CHAWL, ROOM NO 7, SUYOG NAGAR, MUMBAI,
Address
MUMBAI, MAHARASHTRA
PIN 400068
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2/3/25, 9:01 AM View/Print Submitted Form
Police Station BORIVALI
Mobile/Tel No. 7700906932
E-mail [Link].1029@[Link]
Emergency Contact Details
Name and Address AVINASH KADAM
Mobile/Tel No. 7700906932
E-mail [Link].1029@[Link]
Other Details
Payment Details
Mode of Payment UPI
Date 21/01/2025
Receipt/Reference No. CPAESKJXS2
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
[Link] Card issued by the Income Tax Department
[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 MUMBAI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 21/01/2025 to sign)
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