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 25-0004566778

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

Applicant's Name PRASHANT VERMA NADIMPALLI

Date of Birth (DD/MM/YYYY) 21/11/1990

Validity Required NA

Place of Birth (Village/Town/City) JAMSHEDPUR

District EAST SINGHBHUM

State/UT JHARKHAND Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender MALE

Marital Status SINGLE

Citizenship of India by BIRTH

PAN AWLPV6169N

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

Aadhaar Number 884559413409

Family Details

Father's Name SHANKER RAJU NADIMPALLI

Mother's Name RAMESHWARI NADIMPALLI

Legal Guardian's Name SHANKER RAJU NADIMPALLI

Present Residential Address Details

H NO 197 ZONE NO 5, JAMSHEDPUR, EAST SINGHBHUM,

Address
JHARKHAND

PIN 831019

Police Station BIRSHANAGAR

Mobile/Tel No. 8092355323

E-mail [email protected]

Permanent Residential Address

H NO 197 ZONE NO 5, JAMSHEDPUR, EAST SINGHBHUM,

Address
JHARKHAND

PIN 831019

Police Station BIRSHANAGAR

Mobile/Tel No. 8092355323

Emergency Contact Details

Name and Address N SHANKER RAJU

Mobile/Tel No. 7808458181

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

Passport Number M9547989

Date of Issue 29/06/2015

Date of Expiry 28/06/2025

Place of Issue RANCHI

Have you ever applied for passport, but not issued?

File Number 7IND9011218M250

Date of Issue 29/06/2015

Name of passport office where applied RANCHI

Details of Previous/Current Diplomatic/Official Passport

Passport Number M9547989

Date of Issue 29/06/2015

Date of Expiry 28/06/2025

Place of Issue RANCHI

Other Details
Payment Details

Mode of Payment UPI

Date 25/03/2025

Receipt/Reference No. CPAEYQEUX9

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

Enclosures

1.Driving licence issued by the Transport Department of the concerned State Government, having the date of birth of the applicant

2.Aadhaar Card (Address Proof)

3.Affidavit stating how and where the Passport got lost/ damaged as per Annexure F

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 JAMSHEDPUR Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 25/03/2025 to sign)

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