12/11/23, 3:11 PM View/Print Submitted Form

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 23-0022025284

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
RAMESHCHANDRA MANORBHAI
Applicant's Name
PATEL

Date of Birth (DD/MM/YYYY) 13/09/1957

Validity Required NA

Place of Birth (Village/Town/City) KOLHAPUR

District KOLHAPUR
Signature/Left Hand Thumb Impression
State/UT MAHARASHTRA of Illiterate Applicant and Minors who
cannot sign.
Region/Country INDIA

Gender MALE

Marital Status MARRIED

Citizenship of India by BIRTH

Employment Type OTHERS

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 839832869348

Family Details
Father's Name MANORBHAI JOTIRAM PATEL

Mother's Name MANIBEN MANORBHAI PATEL

Spouse's Name RITABEN RAMESHCHANDRA PATEL

Present Residential Address Details
100-E, VAKHAR BHAG, JAIN MANDIR ROAD, MAHAVEER
Address
NAGAR, SANGLI, SANGLI, MAHARASHTRA

PIN 416416

Police Station SANGLI CITY

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12/11/23, 3:11 PM View/Print Submitted Form

Mobile/Tel No. 9422407313

E-mail [email protected]
Permanent Residential Address
100-E, VAKHAR BHAG, JAIN MANDIR ROAD, MAHAVEER
Address
NAGAR, SANGLI, SANGLI, MAHARASHTRA

PIN 416416

Police Station SANGLI CITY

Mobile/Tel No. 9422407313

Emergency Contact Details
MAULIK RAMESHCHANDRA PATEL, 100-E, VAKHAR BHAG,
Name and Address JAIN MANDIR ROAD, MAHAVEER NAGAR, SANGLI, PIN-
416416

Mobile/Tel No. 9850161000

Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number K4724142

Date of Issue 25/07/2012

Date of Expiry 24/07/2022

Place of Issue PUNE

File Number PNEB01180812

Other Details
Payment Details
Mode of Payment UPI

Date 11/12/2023

Receipt/Reference No. CPADIINBC4

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

Enclosures
1.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognized educational board

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 SANGLI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 11/12/2023 to sign)

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