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 24-1012133715

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name THANUJA H

Date of Birth (DD/MM/YYYY) 28/02/1997

Validity Required NA

Place of Birth (Village/Town/City) SHIVAMOGGA

District SHIVAMOGGA

State/UT KARNATAKA

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

Citizenship of India by BIRTH

PAN BSMPT0067P

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? Y

Visible Distinguishing Mark MOLE ON LEFT CHIN

Aadhaar Number 719898891276

Family Details
Father's Name H R HALAPPA

Mother's Name H A ASHA

Spouse's Name RAVINDRA MANJUNATH POOJARI

Present Residential Address Details
Address 11,HOSAKOPPA, HOSAHALLI, SHIVAMOGGA, KARNATAKA

PIN 577202
Police Station TUNGANAGARA

Mobile/Tel No. 7483206207

E-mail [email protected]
Permanent Residential Address
Address 11,HOSAKOPPA, HOSAHALLI, SHIVAMOGGA, KARNATAKA

PIN 577202

Police Station TUNGANAGARA

Mobile/Tel No. 7483206207

Emergency Contact Details
Name and Address RAVINDRA M POOJARI

Mobile/Tel No. 9353950443

E-mail [email protected]
Other Details
Payment Details
Mode of Payment UPI

Date 07/11/2024

Receipt/Reference No. CPAEKWMNN6

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.

Place SHIVAMOGGA Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 25/10/2024 to sign)

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