5/8/24, 4:47 PM APPLICATION FORM FOR INDIAN PASSPORT ARN: 24-2002191292
16 KARA-BULAK STR. (VAKHSHSKAYA) STREET, MIRZO ULUGBEK DISTRICT,TASHKENT-700052,
UZBEKISTAN
00-998-71-1400983 http://eoi.gov.in/tashkent/
PASSPORT PREVIEW
भारत गणराज्य REPUBLIC OF INDIA
पासपोर्ट
टाइप/Type राष्ट्र कोड/CountryCode
नं./PassportNo.
Paste your unsigned recent color photograph of Size 2"X2" and Signature/Left Hand Thumb Impression in the box provided
P IND
Paste your unsigned
उपनाम/Surname
recent color photograph
SAH
Size 2"X2" and
दिया गया नाम/Given Name(s)
Signature/Left Hand CHANDAN KUMAR
Thumb Impression in राष्ट्रीयता/Nationality लिंग/Sex जन्मतिथि/Date of Birth
the box provided below INDIAN M 06/06/1990
जन्म स्थान/Place of Birth
Generated on: Wednesday, May 8, 2024 4:47:32 PM
GOPALPUR, BIHAR
जारी करने का स्थान/Place of Issue
जारी करने की तिथि/Date of Issue समाप्ति की तिथि/Date of Expiry
पिता/कानूनी अभिभावक का नाम/Name of Father/Legal Guardian
SHIV SHANKAR SAH
माता का नाम/Name of Mother
GULAICHI DEVI
पति या पत्नी का नाम/Name of Spouse
ANCHAL KUMARI
पता/Address
VILL- GOPALAPUR
PO- DARAULI, SIWAN
PIN:841234, BIHAR, INDIA
पुराने पासपोर्ट का नं. और इसके जारी होने की तिथि एवं स्थान/Old Passport No with Date and Place of Issue
M0316472 18/07/2014 PATNA
फ़ाइल नं./File No.
Service Required
Application Reference Number (ARN) 24-2002191292
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 36 Pages
Applicant Details
Applicant's Name CHANDAN KUMAR SAH
Applicant's Alias Name N
Applicant's Change In Name N
Date of Birth (DD/MM/YYYY) 06/06/1990
Validity Required NA
Place of Birth (Village/Town/City) GOPALPUR
District SIWAN
State/UT BIHAR
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN EUXPS9796E
Employment Type OTHERS
Is either of your parent (in case of minor)/spouse, a government servant? N
Educational Qualification 10TH PASS AND ABOVE
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5/8/24, 4:47 PM APPLICATION FORM FOR INDIAN PASSPORT ARN: 24-2002191292
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark NO
Aadhaar Number 383841264981
Family Details(as in passport)
Father's Name SHIV SHANKAR SAH
Mother's Name GULAICHI DEVI
Spouse's Name ANCHAL KUMARI
Passport Printable Address Details
To be printed on passport VILL- GOPALAPUR PO- DARAULI, SIWAN PIN:841234, BIHAR, INDIA
Mobile/Telephone Number 918271439646
E-mail CHANDANGOND9060@GMAIL.COM
Other Address Details
Address VILL- GOPALAPUR PO- DARAULI, SIWAN PIN:841234, BIHAR, INDIA
Mobile/Telephone Number 918271439646
Emergency Contact Details
Name and Address CHANDAN KUMAR SAH ENTER STEEL ALMALIK
Mobile/Telephone Number 998901761439
E-mail CHANDANGOND9060@GMAIL.COM
Previous Passport
Passport Number M0316472
Date of Issue 18/07/2014
Date of Expiry 17/07/2024
Place of Issue PATNA
File Number PA1067653334014
Have you ever applied for passport, but not issued? N
Details of Previous/Current Diplomatic/Official Passport N
Other Details
1) Provide the following details if there are any criminal proceedings pending against the applicant.
1.1) Are any proceedings in respect of an offence alleged to have been committed by you pending before a criminal court in India? N
1.2) Has any warrant or summons for your appearance been issued and pending before a court under any law for the time being in force? N
1.3) Has a warrant for your arrest been issued by a court under any law for the time being in force? N
1.4) Has an order prohibiting your departure from India been made by any court? N
2) Provide the following details if the applicant has been convicted by a court in India.
2.1) Have you at any time during the period of five years immediately preceding the date of this application been convicted by a court in India for any offence involving moral
turpitude and sentenced in respect thereof to imprisonment for not less than two years?
N
3) Provide the following details if the applicant has been refused/denied passport.
3.1) Have you ever been refused/denied passport? N
3.2) Has your passport ever been impounded? N
3.3) Has your passport ever been revoked? N
4) Provide the following details if applicant has applied for or been granted foreign citizenship.
4.1) Have you ever applied for or been granted citizenship by any other country? N
4.2) Have you ever held the passport of any other country at any time? N
4.3) Have you ever surrendered your Indian passport? N
4.4) Have you ever applied for renunciation of Indian citizenship? N
5) Provide the following details if applicant has returned to India on Emergency Certificate.
5.1) Have you ever returned to India on Emergency Certificate (EC)? N
5.2) Have you ever been deported from any country? N
5.3) Have you ever been repatriated from any country back to India? N
Self Declaration
I declare:
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.
I understand:
That Ministry of External Affairs (MEA) (or its implementation partner agencies/stakeholders/third parties) may undertake required checks to confirm the accuracy and authenticity of
evidence I have provided and documents I have submitted with this application.
That the information I provide, including biometric data (if any), will be treated in confidence, but it may be disclosed to other government departments, agencies, local authorities,
foreign governments, and other implementation partner agencies/stakeholders/third parties to enable MEA or those bodies to perform their duties.
That providing biometric information, if collected as part of an application, is confirmation of my consent to getting the biometric information checked to verify identity.
That the Passport and related services applications may be handled by the Indian Embassies/Consulates/ Passport Office/other offices including outside of the country in which I have
applied and that this may involve the transfer of my application and supporting documents to and from the respective offices.
That my details may, in certain circumstances, be passed to Police, Intelligence and other Fraud Detection & Prevention agencies. I also understand that such agencies may provide
related information about me to MEA.
Place TASHKENT Signature/Left Hand Thumb Impression of Applicant
Date 08/05/2024 (If applicant is minor, either parent to sign)
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