HAJ COMMITTEE OF INDIA

ONLINE HAJ APPLICATION FORM FOR HAJ – 2024 (C.E.) 1445 (Hijri)

231204202001643
1 .Category General Cover No. MHF-801-2-0
2. No. of Persons 2 No. of Infant 0
3. Name of Cover Head SAIFALI MUSHTAQ KHAN Embarkation Preference 1 /
2 : MUMBAI / HYDERABAD

4. Applicant’s Details (As per International Passport)

Passport Number W2460479 Place of Issue PUNE Date of Issue 04-07-2022

Date of Expiry 03-07-2032 Date of Birth 19-05-1994 Place of Birth PUNE
MUSHTAQ ANWAR AHMED
Surname KHAN First Name SAIFALI Father’s Name
KHAN
Gender Male Mother’s Name FARIDA MUSHTAQ KHAN Spouse’s Name UZMA SAIFALI KHAN
Marital Status MARRIED Blood Group B+ Qualification POST GRADUATE
Occupation PROFESSIONAL Aadhaar No. 9070-7063-0252 PAN No. DBXPK1333P
Companion Name Companion Relation NA

5. Health Details

Detail of Co-Morbidity Not Applicable Pregnancy Status NA

Vaccine Name Covishield

Dose 1 Date 06-08-2021 Dose 2 Date 09-10-2021 Precaution Dose Date

6. Present Residential Address

A/44, GULMOHAR
Address HABITAT-2, SALUNKE Pincode 411040
VIHAR WANOWARIE, PUNE
State Maharashtra District Pune
Mobile Number 9511799053 Mobile Number 2 9823190068 Email Id [email protected]

7. Details of Nominee of Applicant

Name UZMA KHAN Mobile Number : 9527223894

Father’s /Husband’s Name SAIFALI KHAN
Relationship WIFE
A/44, GULMOHAR
Address HABITAT-2, SALUNKE Pincode 411040
VIHAR WANOWARIE, PUNE
Signature / Thumb impression
State Maharashtra District Pune
of Nominee

8. Name of Mehram with Relation (applicable for female pilgrims only)

Name NA Relationship: NA
Signature / Thumb impression
Passport No. NA
of Mehram

9. Bank Account Details

Name of Account Holder KHAN SAIFALI MUSHTAQ Bank Name HDFC BANK
Account No. 50100177138598 IFSC Code HDFC0000831

10. Are you (a) permissible Repeater Mehram / Campanion of age 70+ pilgrim? NO
11. Do you want to perform ADAHI (Qurbani) through IDB ? YES
12. Opting JOHFA Meeqat (only for Shia pilgrims) NO
13. Whether willing to avail facility of Rubat? NO
14. Are you NRI? NO
15. Status of disabilities and type of assistance needed? NA
16. Whether willing to avail Metro facilities in KSA for local travel? NO

• I hereby undertake to abide by all the guidelines, including health protocol, age and travel restrictions, etc. issued by the Kingdom of Saudi Arabia and the Government of India/Haj
Committee of India in view of CoVID-19 pandemic. I agree to travel to the Embarkation Point allotted to me and am ready to pay all the charges on all accounts. I am also willing to go
through the RT-PCR test and quarantine period as specified in the protocol and guidelines
• I am aware of the tentative cost of Haj 2024, which may vary due to operational or functional reasons.
• I certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee
All entries in the above HAF have been checked and found to be in order. Certified that the applicant is eligible to register for Haj-2024 (CE). 1445 (Hijri)
 SOLEMN DECLARATION AND UNDERTAKING

For General Category

I, Mr./Mrs./Miss SAIFALI MUSHTAQ KHAN S/o./W/o./D/o. MUSHTAQ ANWAR AHMED KHAN, an Indian citizen, do hereby solemnly affirm and
declare as under:
1. I am aware that, as per Government of India policy, a person can perform Haj only "Once in a Lifetime" through the Haj Committee of India (HCol).
2. I have never performed Haj through the HCol in the past, and hence I am eligible to apply for Haj - 2024 (Hijri - 1445). I am aware that repeaters are
not eligible for Haj - 2024 (Hijri- 1445) and if it is detected at any stage that I have already performed Haj through HCoI, my seat shall be cancelled and
the entire amount deposited shall be forfeited.
3. I have read / understood thoroughly the Guidelines for Haj - 2024 (Hijri - 1445), particularly with reference to eligibility, cost, payments and
confirmation, cancellation, refunds, embarkation points, vaccination and health requirements before flight, baggage, flight, and accommodation in
Kingdom of Saudi Arabia, and I undertake to abide by the same.
4. I hereby authorize HCol to send SMS to my mobile phone number, even if I am on the DND registry.
5. The particulars given by me in HAF, the solemn declaration, and the undertaking are true and correct to the best of my knowledge. I do hereby affirm
and declare that in the event I have suppressed material information or given a false / incorrect declaration / undertaking, HCoI shall forfeit the amount
deposited by me and I shall be liable for prosecution.
6. I am aware that HCol reserves the right to change the Embarkation point opted by me. In such a case, I shall abide by the decision of HCol and shall
not show any resentment, whatsoever, against the decision of HCoI. I hereby agree to pay the Airfare finalized through the bids for each Embarkation
Point and shall not represent against that.
7. I am ready to pay extra charges, as levied by the KSA Haj authorities, for the endorsement of my Haj visa.
8. I/We understand that the HCoI works without profit motive and does not attract the provisions of the Consumer Protection Act, 2019.
9. Further, we understand that the Courts of Greater Mumbai alone shall have jurisdiction in all matters of dispute.
10. I understand that if I am found carrying khas-khas, viagra-tablets, sexual oil and creams, synthetic capore, cystone, khammera, gutkha, khaini, gul,
peppermint, or narcotics in any form, my candidature shall be cancelled. Besides, I will be penalized for carrying banned items as per the prevailing
regulations of Saudi Arabia, and I will be liable for deportation to India from KSA at any stage of Haj.
11. I hereby agree that the Rubat and metro transport facilities will be subject to the terms and conditions of KSA, and that if this is not possible, I will be
obligated to pay charges for the services provided to me.
12. I do not have any criminal prosecutions pending against me.
13. I am medically fit to perform the Haj pilgrimage and do not have any contagious diseases.
14. I understand that accommodation in Madinah is subject to availability, I may be allotted accommodation in Markazia or Non Markazia as per the
availability. I will accept the accommodation provided to me, which is approved by the authorities in KSA.

Date:___________________________

Place:___________________________

______________________________________________________
Signature / Thumb impression of the applicant.
 HAJ COMMITTEE OF INDIA
ONLINE HAJ APPLICATION FORM FOR HAJ – 2024 (C.E.) 1445 (Hijri)
Adult Pilgrim Detail : 2

231204202001643
1 .Category General Cover No. MHF-801-2-0
2. No. of Persons 2 No. of Infant 0
3. Name of Cover Head SAIFALI MUSHTAQ KHAN Embarkation Preference 1 /
2 : MUMBAI / HYDERABAD

4. Applicant’s Details (As per International Passport)

Passport Number N2566787 Place of Issue PUNE Date of Issue 27-08-2015

Date of Expiry 26-08-2025 Date of Birth 30-10-1970 Place of Birth DAUND
Surname KHAN First Name FARIDA Father’s Name FATTE MOHAMAD MUKERI
MEMUNA FATTE MUSHTAQ ANWAR AHMED
Gender Female Mother’s Name Spouse’s Name
MOHAMAD MUKERI KHAN
Marital Status MARRIED Blood Group O+ Qualification MATRICULATION / SSC
Occupation HOUSE WIFE Aadhaar No. PAN No.
Companion Name Companion Relation NA

5. Health Details

Detail of Co-Morbidity Not Applicable Pregnancy Status No

Vaccine Name Covishield

Dose 1 Date 19-06-2021 Dose 2 Date 27-09-2021 Precaution Dose Date

6. Present Residential Address

A/44, GULMOHAR
Address HABITAT-2, SALUNKE Pincode 411040
VIHAR WANOWARIE, PUNE
State Maharashtra District Pune
Mobile Number 9511799053 Mobile Number 2 Email Id [email protected]

7. Details of Nominee of Applicant

Name RAHIN KHAN Mobile Number : 9511799053

MUSHTAQ ANWAR AHMED
Father’s /Husband’s Name
KHAN
Relationship DAUGHTER
A/44, GULMOHAR
Address HABITAT-2, SALUNKE Pincode 411040
VIHAR WANOWARIE, PUNE
Signature / Thumb impression
State Maharashtra District Pune
of Nominee

8. Name of Mehram with Relation (applicable for female pilgrims only)

Name saifali khan Relationship: SON

Signature / Thumb impression
Passport No. W2460479
of Mehram

9. Bank Account Details

Name of Account Holder KHAN SAIFALI MUSHTAQ Bank Name HDFC BANK
Account No. 50100177138598 IFSC Code HDFC0000831

10. Are you (a) permissible Repeater Mehram / Campanion of age 70+ pilgrim? NO
11. Do you want to perform ADAHI (Qurbani) through IDB ? YES
12. Opting JOHFA Meeqat (only for Shia pilgrims) NO
13. Whether willing to avail facility of Rubat? NO
14. Are you NRI? NO
15. Status of disabilities and type of assistance needed? NA
16. Whether willing to avail Metro facilities in KSA for local travel? NO

• I hereby undertake to abide by all the guidelines, including health protocol, age and travel restrictions, etc. issued by the Kingdom of Saudi Arabia and the Government of India/Haj
Committee of India in view of CoVID-19 pandemic. I agree to travel to the Embarkation Point allotted to me and am ready to pay all the charges on all accounts. I am also willing to go
through the RT-PCR test and quarantine period as specified in the protocol and guidelines
• I am aware of the tentative cost of Haj 2024, which may vary due to operational or functional reasons.
• I certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

 FOR OFFICE USE ONLY
Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee
All entries in the above HAF have been checked and found to be in order. Certified that the applicant is eligible to register for Haj-2024 (CE). 1445 (Hijri)
 SOLEMN DECLARATION AND UNDERTAKING

For General Category

I, Mr./Mrs./Miss FARIDA MUSHTAQ KHAN S/o./W/o./D/o. FATTE MOHAMAD MUKERI, an Indian citizen, do hereby solemnly affirm and declare as
under:
1. I am aware that, as per Government of India policy, a person can perform Haj only "Once in a Lifetime" through the Haj Committee of India (HCol).
2. I have never performed Haj through the HCol in the past, and hence I am eligible to apply for Haj - 2024 (Hijri - 1445). I am aware that repeaters are
not eligible for Haj - 2024 (Hijri- 1445) and if it is detected at any stage that I have already performed Haj through HCoI, my seat shall be cancelled and
the entire amount deposited shall be forfeited.
3. I have read / understood thoroughly the Guidelines for Haj - 2024 (Hijri - 1445), particularly with reference to eligibility, cost, payments and
confirmation, cancellation, refunds, embarkation points, vaccination and health requirements before flight, baggage, flight, and accommodation in
Kingdom of Saudi Arabia, and I undertake to abide by the same.
4. I hereby authorize HCol to send SMS to my mobile phone number, even if I am on the DND registry.
5. The particulars given by me in HAF, the solemn declaration, and the undertaking are true and correct to the best of my knowledge. I do hereby affirm
and declare that in the event I have suppressed material information or given a false / incorrect declaration / undertaking, HCoI shall forfeit the amount
deposited by me and I shall be liable for prosecution.
6. I am aware that HCol reserves the right to change the Embarkation point opted by me. In such a case, I shall abide by the decision of HCol and shall
not show any resentment, whatsoever, against the decision of HCoI. I hereby agree to pay the Airfare finalized through the bids for each Embarkation
Point and shall not represent against that.
7. I am ready to pay extra charges, as levied by the KSA Haj authorities, for the endorsement of my Haj visa.
8. I/We understand that the HCoI works without profit motive and does not attract the provisions of the Consumer Protection Act, 2019.
9. Further, we understand that the Courts of Greater Mumbai alone shall have jurisdiction in all matters of dispute.
10. I understand that if I am found carrying khas-khas, viagra-tablets, sexual oil and creams, synthetic capore, cystone, khammera, gutkha, khaini, gul,
peppermint, or narcotics in any form, my candidature shall be cancelled. Besides, I will be penalized for carrying banned items as per the prevailing
regulations of Saudi Arabia, and I will be liable for deportation to India from KSA at any stage of Haj.
11. I hereby agree that the Rubat and metro transport facilities will be subject to the terms and conditions of KSA, and that if this is not possible, I will be
obligated to pay charges for the services provided to me.
12. I do not have any criminal prosecutions pending against me.
13. I am medically fit to perform the Haj pilgrimage and do not have any contagious diseases.
14. I understand that accommodation in Madinah is subject to availability, I may be allotted accommodation in Markazia or Non Markazia as per the
availability. I will accept the accommodation provided to me, which is approved by the authorities in KSA.

Date:___________________________

Place:___________________________

______________________________________________________
Signature / Thumb impression of the applicant.