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 23-1012439931

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details

Applicant's Name ACHYUTHA NAGA VAISHNAVI GANTI

Date of Birth (DD/MM/YYYY) 21/04/2004

Validity Required NA

Place of Birth (Village/Town/City) SANGAREDDY

District SANGAREDDY

State/UT TELANGANA

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

Citizenship of India by BIRTH

PAN COPPN5794H

Employment Type STUDENT

Is either of your parent (in case of

Y
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 474112693915

Family Details

Father's Name SRINIVAS GANTI

Mother's Name RENUKA DEVI GANTI

Present Residential Address Details

FLAT NO 103, TULASI RESIDENCY, POTHIREDDYPALLY,

Address
SANGAREDDY, SANGAREDDY, TELANGANA

PIN 502295

Police Station SANGAREDDY RURAL

Mobile/Tel No. 7416351670

E-mail GANTIVAISHNAVI92@GMAIL.COM
Emergency Contact Details

Name and Address FLAT NO 103, TULASI RESIDENCY, POTHIREDDYPALLY

Mobile/Tel No. 09490523130

E-mail GANTISEENU@GMAIL.COM
Other Details
Payment Details

Mode of Payment UPI

Date 06/10/2023

Receipt/Reference No. CPADDQKJC5

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

Enclosures

1.Aadhaar Card/E-Aadhaar

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 SANGAREDDY Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 06/10/2023 to sign)

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