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 23-0017677418

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name MOHIT PATIDAR

Date of Birth (DD/MM/YYYY) 03/02/2001

Validity Required NA

Place of Birth (Village/Town/City) CHHAPRI

District SHAJAPUR

State/UT MADHYA PRADESH

Region/Country INDIA
Signature/Left Hand Thumb Impression of Illiterate
Gender MALE Applicant and Minors who cannot sign.
Marital Status SINGLE

Citizenship of India by BIRTH

Employment Type STUDENT

Is either of your parent (in case of minor)/spouse, a

N
government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

Visible Distinguishing Mark MOLE ON FACE

Aadhaar Number 996410277944

Family Details
Father's Name RAKESH PATIDAR

Mother's Name PHOOLWATI PATIDAR

Present Residential Address Details

Address WARD NO 2, CHHAPRI, SHAJAPUR, MADHYA PRADESH

PIN 465337

Police Station KALAPIPAL

Mobile/Tel No. 9977783847

E-mail [email protected]
Permanent Residential Address
Address WARD NO 2, CHHAPRI, SHAJAPUR, MADHYA PRADESH

PIN 465337

Police Station KALAPIPAL

Mobile/Tel No. 9977783847

Emergency Contact Details

Name and Address RAKESH PATIDAR GRAM CHHAPRI TESH KALAPIPAL DIST SHAJAPUR

Mobile/Tel No. 6269293735

E-mail [email protected]

Other Details
Payment Details
Mode of Payment UPI

Date 18/09/2023

Receipt/Reference No. CPADCFKHV5

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

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 SEHORE
Signature/Left Hand Thumb Impression of Applicant (If
applicant is minor, either parent to sign)
Date 18/09/2023

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