8/10/2019 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 19-0011247424
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name DEEPAK KUMAR DAVE
Date of Birth (DD/MM/YYYY) 07/05/1985
Validity Required NA
Place of Birth (Village/Town/City) PALI
District PALI
State/UT RAJASTHAN
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a government servant? N
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark MARK ON HEAD
Aadhaar Number 982154060783
Family Details
Father's Name OM PRAKASH DAVE
Mother's Name INDU BALA DAVE
Spouse's Name KOMAL KIRAN TRIVEDI
Present Residential Address Details
Address 7A, MAHESH COLONY I.T.I. ROAD, PALI, PALI, RAJASTHAN
PIN 306401
Police Station INDUSTRIS AREA
Mobile/Tel No. 9726353665
E-mail DEEPAKKUMAR.DAVE@GMAIL.COM
Permanent Residential Address
Address 7A, MAHESH COLONY I.T.I. ROAD, PALI, PALI, RAJASTHAN
PIN 306401
Police Station INDUSTRIS AREA
Mobile/Tel No. 9726353665
Emergency Contact Details
Name and Address KAPIL DAVE
Mobile/Tel No. 9460693366
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number H6809194
Date of Issue 27/11/2009
Date of Expiry 26/11/2019
Place of Issue JAIPUR
File Number JPRW24147709
Other Details
Enclosures
1.PAN Card issued by the Income Tax Department
2.Self-Passport (unrevoked and undamaged)
Self Declaration
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I owe allegiance to the sovereignty, unity and integrity of India, and have not voluntarily acquired citizenship or travel document of any
8/10/2019 Application Form
other country. I have not lost, surrendered or been deprived of the citizenship of India and I affirm that the information given by me in this
form and the enclosures is true and I am solely responsible for its accuracy, and 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.
Place PALI
Date 10/08/2019

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