2/4/2021 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 21-0001244910
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name MURARI KUMAR ASHOK JHA
Date of Birth (DD/MM/YYYY) 10/03/1995
Validity Required NA
Place of Birth (Village/Town/City) MADHUBANI
District MADHUBANI
State/UT BIHAR
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN AXJPJ6367M
Voter Id ITD7004294
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? N
Aadhaar Number 660458659225
Family Details
Father's Name ASHOK KUMAR JHA
Mother's Name BACHCHI DEVI
Legal Guardian's Name ASHOK KUMAR JHA
Present Residential Address Details
ROOM NO.10, AMBEDKAR NAGAR, KAJUPADA RD, POISAR, KANDIVALI EAST,
Address
MUMBAI, MAHARASHTRA
PIN 400101
Police Station SAMTANAGAR
Mobile/Tel No. 9820321273
E-mail [email protected]
Permanent Residential Address
WARD NO.15,VILL.BALIA PO.-TISI NARSAM, BENIPATTI, MADHUBANI, BIHAR,
Address
INDIA
PIN 847223
Police Station BENIPATTI
Mobile/Tel No. 9082959522
Emergency Contact Details
Name and Address ASHOK KUMAR JHA
Mobile/Tel No. 9867866507
E-mail [email protected]
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Aadhaar Card (Address Proof)
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.

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2/4/2021 Application Form
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 MUMBAI
Date 04/02/2021

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