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This document is a passport application form for Mehulkumar Mali, a male student born on January 27, 2005, from Bhabhar, Gujarat, India. The application is for a fresh normal passport, with a payment of Rs. 1500 made via UPI, and includes necessary personal and family details, along with a self-declaration of the authenticity of the information provided. The applicant affirms allegiance to India and acknowledges the legal implications of providing false information.

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View_Print Submitted Form

This document is a passport application form for Mehulkumar Mali, a male student born on January 27, 2005, from Bhabhar, Gujarat, India. The application is for a fresh normal passport, with a payment of Rs. 1500 made via UPI, and includes necessary personal and family details, along with a self-declaration of the authenticity of the information provided. The applicant affirms allegiance to India and acknowledges the legal implications of providing false information.

Uploaded by

krish209320
Copyright
© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
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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 25-0003109008

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details

Applicant's Name MEHULKUMAR MALI

Date of Birth (DD/MM/YYYY) 27/01/2005

Validity Required NA

Place of Birth (Village/Town/City) BHABHAR

District BANASKANTHA

State/UT GUJARAT

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 ILFPM9669K

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 237673519115

Family Details

Father's Name ASHOKBHAI MALI

Mother's Name MANIBEN MALI


Present Residential Address Details

AMBIKA NAGAR,BHABHAR, BHABHAR JUNA,BANASKANTHA,


Address
BHABHAR, BANASKANTHA, GUJARAT

PIN 385320

Police Station BHABHAR


Mobile/Tel No. 8160244845

E-mail [email protected]
Permanent Residential Address

AMBIKA NAGAR,BHABHAR, BHABHAR JUNA,BANASKANTHA,


Address
BHABHAR, BANASKANTHA, GUJARAT

PIN 385320

Police Station BHABHAR

Mobile/Tel No. 8160244845


Emergency Contact Details

Name and Address SANJAY, BHABHAR AMBIKA NAGAR

Mobile/Tel No. 9737137385

E-mail [email protected]
Other Details
Payment Details

Mode of Payment UPI

Date 23/02/2025

Receipt/Reference No. CPAEVRAWY6

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


Enclosures

1.Permanent Account Number Card issued by the Income-tax Department having the date of birth of the applicant

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 GUJARAT Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 23/02/2025 to sign)

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