12/7/24, 7:48 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-0019238582
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name JAYA VIJAY CHHADEKAR
Date of Birth (DD/MM/YYYY) 15/08/1987
Validity Required NA
Place of Birth (Village/Town/City) PALDHI
District JALGAON
State/UT MAHARASHTRA
Region/Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN APNPC7154D
Employment Type HOME MAKER
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 7TH PASS OR LESS
Are you eligible for Non-ECR category? N
Aadhaar Number 988088271344
Family Details
Father's Name VIJAY VASANT CHHADEKAR
Mother's Name SUSHILABAI VIJAY CHHADEKAR
Present Residential Address Details
Address CHHADEKAR GALLI, PALADHI, JALGAON, MAHARASHTRA
PIN 424205
Police Station DHARANGAON
Mobile/Tel No. 9049176004
E-mail [email protected]
Permanent Residential Address
Address CHHADEKAR GALLI, PALADHI, JALGAON, MAHARASHTRA
PIN 424205
Police Station DHARANGAON
Mobile/Tel No. 9049176004
Emergency Contact Details
Name and Address VIJAY CHHADEKAR
Mobile/Tel No. 9049176004
E-mail [email protected]
Other Details
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.
Place JALGAON
Date 07/12/2024

https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/1