8/11/24, 9:30 PM 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 24-0014058866

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

YEARS/DUE TO EXPIRE. , CHANGE
If Re-issue, specify reason(s)
IN EXISTING PERSONAL
PARTICULARS

If change in existing personal

APPEARANCE , SIGNATURE
particulars, specify

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name TUSHAR GUPTA

Date of Birth (DD/MM/YYYY) 10/09/2004

Validity Required NA Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Place of Birth (Village/Town/City) DELHI cannot sign.
District NORTH DELHI

State/UT DELHI

Region/Country INDIA

Gender MALE

Marital Status SINGLE

Citizenship of India by BIRTH

Employment Type STUDENT

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

Family Details
Father's Name AJAY KUMAR GUPTA

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Mother's Name NIDHI GUPTA

Present Residential Address Details
57,TOP FLOOR,PREM NAGAR GALI NO.2,SHAKTI NAGAR,
Address
DELHI, NORTH DELHI, DELHI

PIN 110007

Police Station ROOP NAGAR

Mobile/Tel No. 9868877975

E-mail [email protected]
Permanent Residential Address
57,TOP FLOOR,PREM NAGAR GALI NO.2,SHAKTI NAGAR,
Address
DELHI, NORTH DELHI, DELHI

PIN 110007

Police Station ROOP NAGAR

Mobile/Tel No. 9868877975

Emergency Contact Details
Name and Address MANAV GUPTA, SHAKTI NAGAR

Mobile/Tel No. 7042232269

Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number R1763013

Date of Issue 01/08/2017

Date of Expiry 31/07/2022

Place of Issue DELHI

File Number DL2061276301217

Other Details
Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)
Fee amount in (Rs)

If paid by Demand Draft(DD), provide the following details

DD Issue Date (dd/mm/yyyy)

DD Expiry Date (dd/mm/yyyy)

Bank Name

Branch
Enclosures
1.PAN Card issued by the Income Tax Department

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

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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 DELHI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 11/08/2024 to sign)

Print Close

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