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 21-1008514949

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details

Applicant's Name SAFRINA

Date of Birth (DD/MM/YYYY) 18/09/1999

Validity Required NA

Place of Birth (Village/Town/City) COIMBATORE

District COIMBATORE

State/UT TAMIL NADU

Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender FEMALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.

Citizenship of India by BIRTH

PAN OODPS6835C

Voter Id RIV2448157L

Employment Type HOME MAKER

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 MOLE ABOVE MOUTH

Aadhaar Number 720248275385

Family Details

Father's Name SHAJAHAN

Mother's Name MEHARAJ

Spouse's Name FIROSEBABU
Present Residential Address Details
Address 93/67 LN STREET, COIMBATORE, COIMBATORE, TAMIL NADU

PIN 641001

Police Station UKKADAM

Mobile/Tel No. 7339379800 / 9944093165

E-mail [email protected]
Permanent Residential Address
Address 93/67 LN STREET, COIMBATORE, COIMBATORE, TAMIL NADU

PIN 641001

Police Station UKKADAM

Mobile/Tel No. 7339379800 / 9944093165

Emergency Contact Details

SAFRINA.S, 93/67, LN STREET ,FORT ,COIMBATORE,

Name and Address
TAMILNADU, 641001

Mobile/Tel No. 7339379800 / 9944093165

E-mail [email protected]
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
1.Birth certificate issued by the Registrar of Births and Deaths or the Municipal Corporation or any other prescribed authority
whosoever has been empowered under the Registration of Birth and Deaths Act, 1969 to register the birth of a child born in India

2.Bank/ Kisan/ Post Office Passbooks

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.

Signature/Left Hand Thumb Impression of

Place COIMBATORE
Applicant (If applicant is minor, either parent
 to sign)
Date 30/11/2021

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