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Narayana has submitted a passport application form for reissue due to a change in his address. He is applying for a normal passport as an Indian citizen by birth. He provides personal details like name, date of birth, place of birth, address, employment, and educational qualifications. He lists his family members and references. He encloses documents and payment details. He declares his allegiance to India and responsibility for the accuracy of the information provided.

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Narayana Mugalur
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25 views

View - Print Submitted Form

Narayana has submitted a passport application form for reissue due to a change in his address. He is applying for a normal passport as an Indian citizen by birth. He provides personal details like name, date of birth, place of birth, address, employment, and educational qualifications. He lists his family members and references. He encloses documents and payment details. He declares his allegiance to India and responsibility for the accuracy of the information provided.

Uploaded by

Narayana Mugalur
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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9/19/2014

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

14-1007957947

Applying For

REISSUE

If Re-issue, specify reason(s)

CHANGE IN EXISTING PERSONAL


PARTICULARS

If change in existing personal


particulars, specify

ADDRESS

Type of Application

NORMAL

Type of Passport Booklet

NORMAL

Applicant Details
Applicant's Name

NARAYANA

Date of Birth (DD/MM/YYYY)

15/05/1961

Place of Birth (Village/Town/City)

MUGALUR

District

TUMKUR

State/UT

KARNATAKA

Country

INDIA

Gender

MALE

Marital Status

MARRIED

Citizenship of India by

BIRTH

PAN

ALSPN0950H

Voter Id

UZJ5484563

Employment Type

OTHERS

Is either of your parent (in case of


minor)/spouse, a government servant?

Educational Qualification

10TH PASS AND ABOVE

Are you eligible for Non-ECR category?

Visible Distinguishing Mark

MOLE BELOW LEFT CHEST

Signature/Left Hand Thumb Impression


of Illiterate Applicant and Minors who
cannot sign.

Family Details
Father's Name

BATAIAH THIMMAIAH

Mother's Name

NINGAMMA

Spouse's Name

YASHODA

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9/19/2014

View/Print Submitted Form

Present Address Details


Residing Since(MM/YYYY)

08/2011

Address

NO.39 1ST CROSS NAVADEEP SCHOOL DEVASANDRA, K R


PURAM, BANGALORE, K R PURAM, BANGALORE,
KARNATAKA

PIN

560036

Mobile/Tel No.

919035832472

E-mail

[email protected]

First Reference Name And Address

DR SUBANDU, RATHNA HOMOEO CLINIC, RAMAMURTHY


NAGAR

Mobile/Tel No.

9845496739

Second Reference Name And Address

DR MANJUNATH, SHAM ENT CLINIC, K R PURAM

Permanent Address
Address

NO.39 1ST CROSS NAVADEEP SCHOOL DEVASANDRA, K R


PURAM, BANGALORE, K R PURAM, BANGALORE,
KARNATAKA

PIN

560036

Mobile/Tel No.

919035832472

Emergency Contact Details


Name and Address

NARAYANA, NO 39, 1ST CROSS, BEHIND NAVADEEP


SCHOOL, DEVASANDRA

Mobile/Tel No.

919035832472

E-mail

[email protected]

Previous Passport/ Application Details


Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number

G1525909

Date of Issue

31/01/2007

Date of Expiry

30/01/2017

Place of Issue

BANGALORE

Payment Details
Mode of Payment

Debit/Credit Card

Date

19/09/2014

Receipt/Reference No.

CP09994818

Amount Received (Rs.)

1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)

Enclosures
1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Self Declaration

I owe allegiance to the sovereignty, unity and 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
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9/19/2014

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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

BANGALORE

Date

19/09/2014

Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
to sign)

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