2/11/24, 4:08 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-0002675336
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED MORE THAN 3 YEARS AGO
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name JAI BHAGWAN
Date of Birth (DD/MM/YYYY) 20/03/1986
Validity Required 10 Years
Place of Birth (Village/Town/City) DHANASARI
District CHARKHI DADRI
State/UT HARYANA
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
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 766231390654
Family Details
Father's Name OM PRAKASH
Mother's Name VED KAUR
Spouse's Name SUNITA BAI
Present Residential Address Details
PO CHANDWAS VILL DHANASARI TEH BADHRA, DHANASARI, CHARKHI
Address
DADRI, HARYANA
PIN 127308
Police Station BADHRA
Mobile/Tel No. 9812028595
E-mail [email protected]
Permanent Residential Address
PO CHANDWAS VILL DHANASARI TEH BADHRA, DHANASARI, CHARKHI
Address
DADRI, HARYANA
PIN 127308
Police Station BADHRA
Mobile/Tel No. 9812028595
Emergency Contact Details
Name and Address SUNITA BAI PO CHANDWAS VILL DHANASARI
Mobile/Tel No. 8930998595
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number H2179258
Date of Issue 06/12/2008
Date of Expiry 05/12/2018
Place of Issue DHANASARI
Other Details
Enclosures
1.PAN Card issued by the Income Tax Department
2.Aadhaar Card (Address Proof)
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2/11/24, 4:08 PM Application Form

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 DHANASARI
Date 11/02/2024
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