4/18/24, 8:29 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 24-0002749904

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.

Type of Application NORMAL

Type of Passport Booklet JUMBO

Applicant Details
Applicant's Name ANSHUL MANGAL

Date of Birth (DD/MM/YYYY) 12/06/1986

Validity Required NA

Place of Birth (Village/Town/City) GWALIOR

District GWALIOR

State/UT MADHYA PRADESH Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender MALE

Marital Status DIVORCED

Citizenship of India by BIRTH

Employment Type SELF EMPLOYED

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 838522019726

Family Details
Father's Name ANIL MANGAL

Mother's Name USHA MANGAL

Present Residential Address Details

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4/18/24, 8:29 PM View/Print Submitted Form

NIMBAL KER KI GODTH NO 2,10 VIKAS COLONEY,

Address
GWALIOR, GWALIOR, MADHYA PRADESH

PIN 474001

Police Station GWALIOR

Mobile/Tel No. 9301381038 / 07514920845

E-mail [email protected]
Permanent Residential Address
NIMBAL KER KI GODTH NO 2,10 VIKAS COLONEY,
Address
GWALIOR, GWALIOR, MADHYA PRADESH

PIN 474001

Police Station GWALIOR

Mobile/Tel No. 9301381038 / 07514920845

Emergency Contact Details
ANIL MANGAL,NIMBAL KAR KI GODTH NO 2,10 VIKAS
Name and Address
COLONEY HUZARAT PULL LASHKER GWALIOR MP 474001

Mobile/Tel No. 8518970435 / 07514920845

E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M0446205

Date of Issue 06/08/2014

Date of Expiry 05/08/2024

Place of Issue GWALIOR

File Number BP08Z0022746213

Other Details
Payment Details
Mode of Payment UPI

Date 12/02/2024

Receipt/Reference No. CPADNBVNE5

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

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
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.

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4/18/24, 8:29 PM View/Print Submitted Form

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 GWALIOR Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 12/02/2024 to sign)

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