8/27/2021 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 21-0003497060  
 
Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name MAYUR PRAKASH TIDKE

Date of Birth (DD/MM/YYYY) 25/06/1999

Validity Required NA   

Place of Birth (Village/Town/City) MUMBAI

District MUMBAI

State/UT MAHARASHTRA

Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors
who
Marital Status SINGLE cannot sign.
 
Citizenship of India by BIRTH  
 
PAN CAMPT8251P

Voter Id IVP7555311

Employment Type OTHERS

Is either of your parent (in case of

Y
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 767385773545

Family Details
Father's Name PRAKASH LAXMAN TIDKE

Mother's Name MANISHA PRAKASH TIDKE

Present Residential Address Details

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8/27/2021 View/Print Submitted Form
Address WANKHEDE CHAWL, VARSHA NAGAR, PARK SITE,
VIKHROLI WEST, MUMBAI, MUMBAI, MAHARASHTRA

PIN 400079

Police Station VIKHROLI

Mobile/Tel No. 9619868423

E-mail [email protected]
Permanent Residential Address
WANKHEDE CHAWL, VARSHA NAGAR, PARK SITE,
Address
VIKHROLI WEST, MUMBAI, MUMBAI, MAHARASHTRA

PIN 400079

Police Station VIKHROLI

Mobile/Tel No. 9619868423

Emergency Contact Details
VIKAS TIDKE , VARSHA NAGAR, PARK SITE , VIKHROLI
Name and Address
WEST, MUMBAI400079

Mobile/Tel No. 9967220038

E-mail [email protected]
Other Details
Payment Details
Mode of Payment Debit/Credit Card

Date 13/04/2021

Receipt/Reference No. CPAATYJBY2

Amount Received (Rs.) 1500.00  (ONE THOUSAND FIVE HUNDRED ONLY)

Enclosures
1.Birth certificate issued by the Registrar of Births and Deaths or the Municipal Corporation or any other prescribed authority
whosoever has been empowered under the Registration of Birth and Deaths Act, 1969 to register the birth of a child born in India

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 MUMBAI Signature/Left Hand Thumb Impression of

Applicant
(If applicant is minor, either parent
Date 13/04/2021 to sign)

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