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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 - 24-0047749212
Please paste
Number your unsigned
Applying For - FRESH recent color
Type of Application - NORMAL photograph of
size 4.5cm *
Type of Passport - NORMAL 3.5cm.
Booklet

Applicant Details
Applicant's Name - AKSHAY SHRAWANJI LICHADE
Date of Birth - 29/03/1996
(DD/MM/YYYY)
Validity Required - NA
Signature/Left Hand Thumb
Place Of Birth - NAGPUR Impression of Illiterate Applicant
(Village/Town/City) and Minors who cannot sign.
District - NAGPUR CITY
State/UT - MAHARASHTRA
Region/Country - INDIA
Gender - MALE
Marital Status - SINGLE
Citizenship of India by - BIRTH
Employment Type - STUDENT
Is either of your - N
parent (in case of
minor)/spouse, a
government servant?
Educational - GRADUATE AND ABOVE
Qualification
Are you eligible for - Y
Non-ECR category
Aadhaar Number - 423389757574

Family Details
Father Name - SHRAWANJI GOVINDRAO LICHADE
Mother Name - CHAYA SHARAWANJI LICHADE

Present Residential Address Details:

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Address - PLOT NO 1 MAULI NAGAR KHADGAON ROAD, WADI NAGPUR, NAGPUR

CITY, MAHARASHTRA
Pin - 440023
Police Station - WADI
Mobile/Tel No - 9881392093
Email - [email protected]

Permanent Residential Address Details

Address - PLOT NO 1 MAULI NAGAR KHADGAON ROAD, WADI NAGPUR, NAGPUR
CITY, MAHARASHTRA
Pin - 440023
Police Station - WADI
Mobile/Tel No - 9881392093

EmergencyContactDetails:
Name and Address - CHAYA SHRAWANJI LICHADE PLOT NO 1 MAULI NAGAR KHADGAON
ROAD WADI NAGPUR
Mobile/Tel No. - 9527756969

Previous Passport

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. Aadhaar Card (Address Proof)2. PAN Card issued by the Income Tax Department

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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 - NAGPUR Signature/Left Hand Thumb

Impression of Applicant (If applicant
Date - 09/08/2024 is minor, either parent to sign)

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