File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS PASSPORT APPLICATION FORM

1. Service Required 1.1 Applying for Fresh Passport Re-issue of Passport Exhaustion of Pages Lost Passport Damaged Passport 1.2 If re-issue, specify reason(s) Validity Expired within 3 years/ Due to Expire Validity Expired more than 3 years ago Change in Existing Personal Particulars Appearance Surname Address Signature Date of Birth Delete ECR Given Name Spouse Name Others, Please specify

Please paste your unsigned recent colour photograph with white background of size 4.5cm X 3.5cm. [Not needed for applicants submitting the application at Passport Seva Kendra]

1.3 If change in existing personal particulars, specify reason(s)

Signature/ Left Hand Thumb Impression of Illiterate Applicant and Minors who cannot sign.

1.4 Type of Application 1.5 Type of Passport Booklet

Normal 36 Pages 10 Years

Tatkaal 60 Pages Up to age 18

1.6 Validity Required

2. Applicant Details 2.1 Applicant's Given Name (Given Name means First name followed by Middle name (If any))(Initials not allowed)

Surname

2.2 Are you known by any other names (aliases)? If yes, provide details in Column 1 of Supplementary Form 2.3 Have you ever changed your name? If yes, provide details in Column 2 of Supplementary Form

Yes Yes

No No Page 1 of 6

2.4 Date of Birth (DD-MM-YYYY)

2.5 Place of Birth (Village or Town or City)

District (If born in India)

State/ UT (If born in India)

Country (If born abroad) If born before 15/08/1947 in a place now in Pakistan or Bangladesh, write "Undivided India"

2.6 Gender 2.7 Marital Status

Male Single

Female Married Birth Divorced Descent 2.10 Voter ID (If available) Widow/ Widower Separated Registration/ Naturalization

2.8 Citizenship of India by 2.9 PAN (If available)

2.11 Employment Type PSU Private Others Government Homemaker Statutory Body Not Employed Retired Government Servant Retired-Private Service Self Employed Student

Owners, Partners & Directors of companies which are members of CII, FICCI & ASSOCHAM

2.12 If employed in Government/ Statutory Body/ PSU, specify organization name

2.13 Is either of your parent (in case of minor)/ spouse, a government servant? 2.14 Educational Qualification 5th pass or less 10th pass and above Between 6th and 9th Standard Graduate and above Yes

Yes

No

2.15 Are you eligible for Non-ECR category? 2.16 Visible Distinguishing Mark

No For details, see Column 2.15, section B of Instruction Booklet

3. Family Details Page 2 of 6

3.1 Father's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)

Surname

3.2 Mother's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)

Surname

3.3 Legal Guardian's Given Name (If applicable) (Initials not allowed)

Surname

3.4 Spouse's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)

Surname

3.5 If applicant is minor, provide following details Parent's Passport Details (If passport has been applied for but not received, give File Number) Father/ Legal Guardian's File/ Passport Number Father/ Legal Guardian's Nationality, if not Indian

Mother/ Legal Guardian's File/ Passport Number

Mother/ Legal Guardian's Nationality, if not Indian

4. Present Residential Address Details (Where applicant presently resides) 4.1 Residing Since (MM-YYYY) If you have been residing at your present residential address for less than one year, mention the previous address(es) in Column 3 of Supplementary Form. If you are on a temporary visit to India, fill Column 5 of Supplementary Form. Page 3 of 6

4.2 House No. and Street Name

Village or Town or City

District

Police Station

State/ UT

PIN

Mobile Number

Telephone Number

E-mail ID

4.3 Is permanent address same as present address? 5. Emergency Contact Details

Yes

No If no, provide details in Column 4 of Supplementary Form

Name and Address (Mention address only if different from present residential address)

Mobile Number

Telephone Number

E-mail ID

Page 4 of 6

6. References in your Village or Town or City 6.1 First Reference Name and Address

Mobile Number

Telephone Number

6.2 Second Reference Name and Address

Mobile Number

Telephone Number

7. Previous Passport/ Application Details 7.1 Details of latest held/ existing/ lost/ damaged ordinary passport Passport Number Date of Issue (DD-MM-YYYY) Place of Issue Date of Expiry (DD-MM-YYYY) -

If you have held/ hold any diplomatic/ official passport, provide details in Column 6 of Supplementary Form 7.2 Have you ever applied for passport, but not issued? File Number No If yes, provide the following Yes details Month and Year of applying Name of passport office where applied

8. Other details 8.1 Have you ever been charged with criminal proceedings or any arrest warrant/ summon pending before a court in India? If yes, fill Column 7.1 of Supplementary Form Yes No

Page 5 of 6

8.2 Have you at any time during the period of 5 years immediately preceding the date of this application been convicted by a court in India for any criminal offence & sentenced to imprisonment for two years or more? If yes, fill Column 7.2 of Supplementary Form

Yes

No

8.3 Have you ever been refused or denied passport? Yes If yes, give reason for refusal or denial of Passport in Column 7.3 of Supplementary Form 8.4 Has your Passport ever been Impounded or Revoked? Yes If yes, provide details in Column 7.4 of Supplementary Form 8.5 Have you ever applied for/ been granted political asylum to/ by any foreign country? Yes If yes, provide details in Column 7.5 of Supplementary Form 8.6 Have you ever returned to India on Emergency Certificate (EC) or were ever deported Yes or repatriated? If yes, provide details in Column 7.6 of Supplementary Form 9. Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra) 9.1 Fee amount in (Rs) 9.2 If paid by Demand Draft (DD), provide the following details DD Number

No No No No

DD Issue Date Bank Name -

DD Expiry Date -

Branch

10. Enclosures 1. 2. 3. 4. 5. 11. 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 and I affirm that the information given by me in this form and the enclosures is true and I am solely responsible for its accuracy, and 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. Place Signature/ Left Hand Thumb Impression of Applicant (If applicant is Date (DD-MM-YYYY) minor, either parent to sign) Page 6 of 6 6. 7. 8. 9. 10.