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Application Form

The document is a passport application form for an Indian citizen named Shailandra Singh Baghel. [1] He is applying for a re-issue of his passport since his current passport's validity is expiring within 3 years. [2] The application provides his personal details like date of birth, place of birth, address, contact information, as well as details of his current passport. [3] He declares that he owes allegiance to India and is not acquiring citizenship of any other country.

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Saurabh Shrivastava
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77 views2 pages

Application Form

The document is a passport application form for an Indian citizen named Shailandra Singh Baghel. [1] He is applying for a re-issue of his passport since his current passport's validity is expiring within 3 years. [2] The application provides his personal details like date of birth, place of birth, address, contact information, as well as details of his current passport. [3] He declares that he owes allegiance to India and is not acquiring citizenship of any other country.

Uploaded by

Saurabh Shrivastava
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 22-0001485128
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SHAILANDRA SINGH BAGHEL
Date of Birth (DD/MM/YYYY) 01/02/1974
Validity Required NA
Place of Birth (Village/Town/City) REWA
District REWA
State/UT MADHYA PRADESH
Region/Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type SELF EMPLOYED
Is either of your parent (in case of minor)/spouse, a government
N
servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark MOLE IN LIPS
Aadhaar Number 329481834128
Family Details
Father's Name TUNGNATH SINGH BAGHEL
Mother's Name SARASWATI SINGH
Spouse's Name MEENAKSHI SINGH
Present Residential Address Details
HIG 65 BEHIND P.K. SCHOOL, JPN NAGAR, REWA, REWA, MADHYA
Address
PRADESH
PIN 486001
Police Station AMAHIYA
Mobile/Tel No. 9424660766
E-mail [email protected]
Permanent Residential Address
HIG 65 BEHIND P.K. SCHOOL, JPN NAGAR, REWA, REWA, MADHYA
Address
PRADESH
PIN 486001
Police Station AMAHIYA
Mobile/Tel No. 9424660766
Emergency Contact Details
Name and Address MEENAKSHI SINGH
Mobile/Tel No. 9425110716
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J8477120
Date of Issue 29/03/2012
Date of Expiry 28/03/2022
Place of Issue BHOPAL
File Number BPLT00147612
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.
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 REWA
Date 01/02/2022

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