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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 Number 24-1014497429

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 NORMAL

Applicant Details
Applicant's Name KARTHIKAN MUNUSWAMY

Date of Birth (DD/MM/YYYY) 02/08/1985

Validity Required NA

Place of Birth (Village/Town/City) CHENNAI

District CHENNAI

State/UT TAMIL NADU Signature/Left Hand Thumb Impression

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

Marital Status MARRIED

Citizenship of India by BIRTH

PAN AVWPK3625L

Employment Type PRIVATE

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? N

Visible Distinguishing Mark SCAR MARK ON THE NOSE

Aadhaar Number 918626947237

Family Details
Father's Name BOKA MUNUSWAMY

Mother's Name SATHYA MUNUSWAMY

Spouse's Name THAARINI CHINNARAJ

Present Residential Address Details

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12/15/24, 5:13 PM View/Print Submitted Form

NO.50, KANVI, 4TH A CROSS,MUNESHWARA NAGAR,

Address
KATTIGENAHALLI, BENGALURU, KARNATAKA

PIN 560063

Police Station YELAHANKA

Mobile/Tel No. 9686031383

E-mail [email protected]
Permanent Residential Address
NO.50, KANVI, 4TH A CROSS,MUNESHWARA NAGAR,
Address
KATTIGENAHALLI, BENGALURU, KARNATAKA

PIN 560063

Police Station YELAHANKA

Mobile/Tel No. 9686031383

Emergency Contact Details
THAARINI, 50, 4TH A CROSS,MUNESHWARA NAGAR,
Name and Address
KATTIGENAHALLI , BANGALORE - 560063

Mobile/Tel No. 7760038105

E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M3222587

Date of Issue 29/10/2014

Date of Expiry 28/10/2024

Place of Issue BANGALORE

File Number BN2078030932514

Other Details
Payment Details
Mode of Payment UPI

Date 28/11/2024

Receipt/Reference No. CPAEMWNCP1

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED 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.
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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12/15/24, 5:13 PM View/Print Submitted Form

Place BENGALURU Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 28/11/2024 to sign)

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