3/17/24, 5:48 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 24-0004404430
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name DEVENDRA
Date of Birth (DD/MM/YYYY) 20/07/1999
Validity Required NA
Place of Birth (Village/Town/City) VILLAGE TARAINI
District SANT KABIR NAGAR
State/UT UTTAR PRADESH
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 GVUPD9027D
Employment Type OTHERS
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
Visible Distinguishing Mark CUT MARK RIGHT SIDE KNEE
Aadhaar Number 921783219581
Family Details
Father's Name JHINKAN
Mother's Name SONMATI DEVI
Legal Guardian's Name JHINKAN
Present Residential Address Details
VILLAGE AND POST TARAINI TEHSIL KHALILABAD, TARAINI,
Address
SANT KABIR NAGAR, UTTAR PRADESH
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3/17/24, 5:48 PM View/Print Submitted Form
PIN 272164
Police Station MAHULI
Mobile/Tel No. 7408548435
E-mail DY997646@GMAIL.COM
Permanent Residential Address
VILLAGE AND POST TARAINI TEHSIL KHALILABAD, TARAINI,
Address
SANT KABIR NAGAR, UTTAR PRADESH
PIN 272164
Police Station MAHULI
Mobile/Tel No. 7408548435
Emergency Contact Details
JHINKAN YADAV VILLAGE AND POST TARAINI TEHSIL
Name and Address KHALILABAD DISTRICT SANT KABIR NAGAR STATE UTTAR
PRADESH
Mobile/Tel No. 8423600609
Other Details
Payment Details
Mode of Payment Online/Internet Banking
Date 15/03/2024
Receipt/Reference No. IGAQZPTBD6
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 KHALILABAD Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 15/03/2024 to sign)
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