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 25-0004566778
Applying For REISSUE
VALIDITY EXPIRED WITHIN 3
If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name PRASHANT VERMA NADIMPALLI
Date of Birth (DD/MM/YYYY) 21/11/1990
Validity Required NA
Place of Birth (Village/Town/City) JAMSHEDPUR
District EAST SINGHBHUM
State/UT JHARKHAND 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 AWLPV6169N
Employment Type PRIVATE
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 884559413409
Family Details
Father's Name SHANKER RAJU NADIMPALLI
Mother's Name RAMESHWARI NADIMPALLI
Legal Guardian's Name SHANKER RAJU NADIMPALLI
Present Residential Address Details
H NO 197 ZONE NO 5, JAMSHEDPUR, EAST SINGHBHUM,
Address
JHARKHAND
PIN 831019
Police Station BIRSHANAGAR
Mobile/Tel No. 8092355323
E-mail PRASHANTVRM029@[Link]
Permanent Residential Address
H NO 197 ZONE NO 5, JAMSHEDPUR, EAST SINGHBHUM,
Address
JHARKHAND
PIN 831019
Police Station BIRSHANAGAR
Mobile/Tel No. 8092355323
Emergency Contact Details
Name and Address N SHANKER RAJU
Mobile/Tel No. 7808458181
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M9547989
Date of Issue 29/06/2015
Date of Expiry 28/06/2025
Place of Issue RANCHI
Have you ever applied for passport, but not issued?
File Number 7IND9011218M250
Date of Issue 29/06/2015
Name of passport office where applied RANCHI
Details of Previous/Current Diplomatic/Official Passport
Passport Number M9547989
Date of Issue 29/06/2015
Date of Expiry 28/06/2025
Place of Issue RANCHI
Other Details
Payment Details
Mode of Payment UPI
Date 25/03/2025
Receipt/Reference No. CPAEYQEUX9
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
[Link] licence issued by the Transport Department of the concerned State Government, having the date of birth of the applicant
[Link] Card (Address Proof)
[Link] stating how and where the Passport got lost/ damaged as per Annexure F
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 JAMSHEDPUR Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 25/03/2025 to sign)
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