12/17/24, 2:19 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-1015284311
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name C SIVAN
Date of Birth (DD/MM/YYYY) 17/05/1991
Validity Required NA
Place of Birth (Village/Town/City) DHARMAPURI
District DHARMAPURI
State/UT TAMIL NADU
Region/Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 890785236564
Family Details
Father's Name CHINNASAMY
Mother's Name SAROJA
Spouse's Name ANNALAKSHMI
Present Residential Address Details
DNO.19/160,MUNISHWAR NAGAR,S M NAGAR EXTENSION,
Address
MOOKANDAPALLI,HOSUR,, KRISHNAGIRI, TAMIL NADU
PIN 635109
Police Station HOSUR
Mobile/Tel No. 9994812202
E-mail [email protected]
Permanent Residential Address
DNO.19/160,MUNISHWAR NAGAR,S M NAGAR EXTENSION,
Address
MOOKANDAPALLI,HOSUR,, KRISHNAGIRI, TAMIL NADU
PIN 635109
Police Station HOSUR
Mobile/Tel No. 9994812202
Emergency Contact Details
Name and Address ANNALAKSHMI
Mobile/Tel No. 7094648508
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
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/2
12/17/24, 2:19 PM Application Form
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 HOSUR
Date 17/12/2024

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 2/2