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Application Form P-Mosamiben

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hardik22222290
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10 views2 pages

Application Form P-Mosamiben

Uploaded by

hardik22222290
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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View/Print Submitted Form https://portal1.passportindia.gov.in/AppOnlineProject/secure...

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.

Application Reference Number 24-0000788298

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

MOSAMIBEN DHARMENDRABHAI
Applicant's Name
PANCHAL

Date of Birth (DD/MM/YYYY) 24/09/1992

Validity Required NA

Place of Birth (Village/Town/City) RALISANA

District MEHSANA

State/UT GUJARAT

Region/Country INDIA Signature/Left Hand Thumb Impression


of Illiterate Applicant and Minors who
Gender FEMALE
cannot sign.
Marital Status MARRIED

Citizenship of India by BIRTH

PAN BPGPP2119K

Voter Id RVZ3014354

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 865713116473

Father's Name JAYANTIBHAI PATEL

Spouse's Name DHARMENDRABHAI SUSHILBHAI PANCHAL

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View/Print Submitted Form https://portal1.passportindia.gov.in/AppOnlineProject/secure...

24, OM RESIDENCY, NEAR KIRTIDHAM SOCIETY, VAVOL,


Address
GANDHINAGAR, GUJARAT

PIN 382016

Police Station SECTOR-7

Mobile/Tel No. 6353574549

E-mail [email protected]

24, OM RESIDENCY, NEAR KIRTIDHAM SOCIETY, VAVOL,


Address
GANDHINAGAR, GUJARAT

PIN 382016

Police Station SECTOR-7

Mobile/Tel No. 6353574549

Name and Address DHARMENDRA PANCHAL VAVOL GANDHINAGAR

Mobile/Tel No. 9510932056

Mode of Payment UPI

Date 21/01/2024

Receipt/Reference No. CPADLNBZS0

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)

1.Election Photo Identity Card (EPIC) issued by the Election Commission of India

2.Aadhaar Card (Address Proof)

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 GANDHINAGAR Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 20/01/2024 to sign)

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