3/20/24, 2:15 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 24-1003783201

Applying For FRESH

Type of Application TATKAAL

Type of Passport Booklet JUMBO

Applicant Details
Applicant's Name PRATHIK RAM VENKATESH

Date of Birth (DD/MM/YYYY) 07/03/2004

Validity Required NA

Place of Birth (Village/Town/City) THOOTHUKUDI

District THOOTHUKUDI

State/UT TAMIL NADU

Region/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 CTOPV9662G

Voter Id UPG2753887

Employment Type STUDENT

Is either of your parent (in case of

Y
minor)/spouse, a government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

MOLE ON THE LEFT SIDE OF

Visible Distinguishing Mark
FOREHEAD

Aadhaar Number 333012221774

Family Details
Father's Name VENKATESH RAMACHANDRAN

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Mother's Name ANITHA VENKATESH

Present Residential Address Details
NO-2 BOLTENPURAM 1ST STREET,THOOTHUKUDI-3,
Address
THOOTHUKUDI, THOOTHUKUDI, L/�@ C@

PIN 628003

Police Station THOOTHUKUDI SOUTH

Mobile/Tel No. 9751647380

E-mail [email protected]
Permanent Residential Address
NO-2 BOLTENPURAM 1ST STREET,THOOTHUKUDI-3,
Address
THOOTHUKUDI, THOOTHUKUDI, L/�@ C@

PIN 628003

Police Station THOOTHUKUDI SOUTH

Mobile/Tel No. 9751647380

Emergency Contact Details
VENKATESH R, NO-2 BOLTENPURAM 1ST
Name and Address
STREET,THOOTHUKUDI-3,TAMIL NADU

Mobile/Tel No. 9344696969

E-mail [email protected]
Other Details
Payment Details
Mode of Payment UPI

Date 20/03/2024

Receipt/Reference No. CPADQLROC1

Amount Received (Rs.) 2000.00 (TWO THOUSAND ONLY)

Enclosures
1.Driving License issued by the Transport department of concerned state Government

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.

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Place THOOTHUKUDI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 20/03/2024 to sign)

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