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This document is a passport application form for MD Ezaz Alam, a male student born on January 16, 2005, from Nurullahpur, Bihar, India. The application is for a fresh normal passport booklet and includes personal details, family information, and a declaration of the authenticity of the provided information. The payment of Rs. 2000 was made via UPI on February 9, 2025, and the applicant has submitted necessary documents such as PAN and Aadhaar cards.

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23 views

View_Print Submitted Form

This document is a passport application form for MD Ezaz Alam, a male student born on January 16, 2005, from Nurullahpur, Bihar, India. The application is for a fresh normal passport booklet and includes personal details, family information, and a declaration of the authenticity of the provided information. The payment of Rs. 2000 was made via UPI on February 9, 2025, and the applicant has submitted necessary documents such as PAN and Aadhaar cards.

Uploaded by

digiworld9555
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© © All Rights Reserved
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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 25-0002275812

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet JUMBO

Applicant Details

Applicant's Name MD EZAZ ALAM

Date of Birth (DD/MM/YYYY) 16/01/2005

Validity Required NA

Place of Birth (Village/Town/City) NURULLAHPUR

District BEGUSARAI

State/UT BIHAR

Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status SINGLE cannot sign.

Citizenship of India by BIRTH

PAN FPAPA1627B

Employment Type STUDENT

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 416989786743

Family Details

Father's Name MD DASTGIR

Mother's Name RABINA KHATOON

Legal Guardian's Name MD DASTGIR

Present Residential Address Details


Address WARD NO 03, NURULLAHPUR, BEGUSARAI, BIHAR

PIN 848202

Police Station KHODAWANPUR

Mobile/Tel No. 9234779412

E-mail [email protected]

Permanent Residential Address

Address WARD NO 03, NURULLAHPUR, BEGUSARAI, BIHAR

PIN 848202

Police Station KHODAWANPUR

Mobile/Tel No. 9234779412

Emergency Contact Details

Name and Address MD DASTGIR

Mobile/Tel No. 8863006319

Other Details
Payment Details

Mode of Payment UPI

Date 09/02/2025

Receipt/Reference No. CPAEUFUHK9

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.
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 NURULLAHPUR Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 08/02/2025 to sign)

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