4/4/2021 APPLICATION FORM FOR INDIAN PASSPORT

EMBASSY OF INDIA
BUILDING 1090, ROAD NO. 2819, BLOCK NO.428, AL-SEEF, MANAMA, PO
BOX 26106, KINGDOM OF BAHRAIN
00-973-17712683, https://eoi.gov.in/bahrain/
APPLICATION FORM FOR INDIAN PASSPORT
Generated On: 4/4/2021, 7:44:38 AM
PASSPORT PREVIEW

भारत गणरा REPUBLIC OF INDIA

टाइप/Type रा कोड/CountryCode पासपोट नं./PassportNo.

Paste your P IND  

unsigned recent उपनाम/Surname

color photograph LAKSHMIPATHY 

Size 2"X2" and िदया गया नाम/Given Name(s)

Signature/Left PRADEEP
Hand Thumb रा ीयता/Nationality िलंग/Sex ज ितिथ/Date of Birth

Impression in the INDIAN M 30/08/1970

box provided below ज थान/Place of Birth

BANGALORE, KARNATAKA 
जारी करने का थान/Place of Issue
 
जारी करने की ितिथ/Date of Issue समा की ितिथ/Date of Expiry
   

िपता/कानूनी अिभभावक का नाम/Name of Father/Legal Guardian

TUMKUR VENKATRAMIAH LAKSHMIPATHY  

माता का नाम/Name of Mother

BADRAVATHI R PRABHAVATHY   
पित या प ी का नाम/Name of Spouse

MYSORE SANDHYA   
पता/Address

237, 2A MAIN, 11TH CROSS, 1ST BLOCK, BEL LAYOUT

VIDYARANYAPURA, BENGALURU
PIN:560097, KARNATAKA, INDIA 
पुराने पासपोट का नं. और इसके जारी होने की ितिथ एवं थान/Old Passport No with Date and Place of Issue

J6407535  13/07/2011  BAHRAIN

फ़ाइल नं./File No.

Note: Please paste your unsigned recent color photograph Size 2"X2" and Signature/Left Hand Thumb Impression in the box provided above.

SERVICE REQUIRED
Application Reference Number 21-2000697460
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
If change in existing personal particulars, specify
If other, specify
Type of Application NORMAL
Type of Passport Booklet 36 Pages
APPLICANT DETAILS
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Applicant's Name PRADEEP LAKSHMIPATHY

Applicant's Alias Name N
Alias Name1
Alias Name2
Applicant's Change In Name N
Previous Name1
Previous Name2
Date of Birth (DD/MM/YYYY) 30/08/1970
Validity Required NA
Place of Birth (Village/Town/City) BANGALORE
District BENGALURU
State/UT KARNATAKA
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN AYPPP7953A
Voter Id
Employment Type PRIVATE
Organisation name
Is either of your parent (in case of minor)/spouse, a government
N
servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark NIL
Aadhaar Number 825670327869

FAMILY DETAILS
Father's Name TUMKUR VENKATRAMIAH LAKSHMIPATHY
Mother's Name BADRAVATHI R PRABHAVATHY
Legal Guardian's Name
Spouse's Name MYSORE SANDHYA
Father's Passport No
Father's Nationality
Mother's Passport No
Mothers's Nationality
PASSPORT PRINTABLE ADDRESS DETAILS
237, 2A MAIN, 11TH CROSS, 1ST BLOCK, BEL LAYOUT
To be printed on passport VIDYARANYAPURA, BENGALURU
PIN:560097, KARNATAKA, INDIA
Mobile/Tel No. 6363613136 / 06363613436
E-mail [email protected]
OTHER ADDRESS DETAILS
FLAT 41, BUILDING 58
Address ROAD 2701, BLOCK 327
ADLIYA, BAHRAIN
Mobile/Tel No. 97336766090 / 97317551666
EMERGENCY CONTACT DETAILS

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Name and Address NO. 237, 11TH CROSS, 2A MAIN, 1ST BLOCK, BEL LAYOUT,
VIDYARANYAPURA, BANGALORE 97
Mobile/Tel No. 06363613436 / 97336766090
E-mail [email protected]
PREVIOUS PASSPORT
DETAILS OF LATEST HELD/EXISTING/LOST/DAMAGED
Y
ORDINARY PASSPORT/ IDENTITY CERTIFICATE
Passport Number J6407535
Date of Issue 13/07/2011
Date of Expiry 12/07/2021
Place of Issue BAHRAIN
File Number bhrap1532111
HAVE YOU EVER APPLIED FOR PASSPORT, BUT NOT
N
ISSUED?
File Number
Date of Issue
Name of passport office where applied
DETAILS OF PREVIOUS/CURRENT
N
DIPLOMATIC/OFFICIAL PASSPORT
Passport Number
Date of Issue
Date of Expiry
Place of Issue
1) Provide the following details if there are any criminal proceedings
pending against the applicant.
1.1) Are any proceedings in respect of an offence alleged to have been
N
committed by you pending before a criminal court in India?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.2) Has any warrant or summons for your appearance been issued and
N
pending before a court under any law for the time being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.3) Has a warrant for your arrest been issued by a court under any law
N
for the time being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.4) Has an order prohibiting your departure from India been made by
N
any court?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
2) Provide the following details if the applicant has been convicted by a
court in India.
2.1) Have you at any time during the period of five years immediately N
preceding the date of this application been convicted by a court in India

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for any offence involving moral turpitude and sentenced in respect
thereof to imprisonment for not less than two years?
Court Name and Place
Case/FIR/Warrant Number
Date of Conviction
3) Provide the following details if the applicant has been refused/denied
passport.
3.1) Have you ever been refused/denied passport? N
Reason for refusal or denial of passport
3.2) Has your passport ever been impounded? N
Passport Number
Reason for impounding/revocation
3.3) Has your passport ever been revoked? N
Passport Number
Reason for revocation
4) Provide the following details if applicant has applied for or been
granted foreign citizenship.
4.1) Have you ever applied for or been granted citizenship by any other
N
country?
Name of the country
4.2) Have you ever held the passport of any other country at any time? N
Name of the country
4.3) Have you ever surrendered your Indian passport? N
Surrendered Indian passport number:
4.4) Have you ever applied for renunciation of Indian citizenship? N
Application Details:
Name of place where application submitted:
5) Provide the following details if applicant has returned to India on
Emergency Certificate.
5.1) Have you ever returned to India on Emergency Certificate (EC)? N
EC No.
Date of Issue
Issuing Authority
Country from where travelled on EC/deported/repatriated
Date of Return to India
Reason for issuing EC/deported/ repatriated
5.2) Have you ever been deported from any country? N
If yes, was the cost borne by the Government of India and if so, has the
same been refunded?
5.3) Have you ever been repatriated from any country back to India? N
If yes, was the cost borne by the Government of India and if so, has the
same been refunded?
SELF DECLARATION
I declare:

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.

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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.

I understand:

That Ministry of External Affairs (MEA) (or its implementation partner agencies/stakeholders/third parties) may undertake required
checks to confirm the accuracy and authenticity of evidence I have provided and documents I have submitted with this application.

That the information I provide, including biometric data (if any), will be treated in confidence, but it may be disclosed to other
government departments, agencies, local authorities, foreign governments, and other implementation partner

agencies/stakeholders/third parties to enable MEA or those bodies to perform their duties.

That providing biometric information, if collected as part of an application, is confirmation of my consent to getting the biometric

information checked to verify identity.

That the Passport and related services applications may be handled by the Indian Embassies/Consulates/ Passport Office/other

offices including outside of the country in which I have applied and that this may involve the transfer of my application and

supporting documents to and from the respective offices.

That my details may, in certain circumstances, be passed to Police, Intelligence and other Fraud Detection & Prevention agencies. I

also understand that such agencies may provide related information about me to MEA.

MANAMA
Place Signature/Left Hand Thumb Impression of Applicant
BAHRAIN
(If applicant is minor, either parent to sign)
Date 24/02/2021

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