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 24-1001946801
Applying For FRESH
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name AJIJUL MAJHI
Date of Birth (DD/MM/YYYY) 15/12/1997
Validity Required NA
Place of Birth (Village/Town/City) CHARAVIDYA
District BARUIPUR
State/UT WEST BENGAL
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.
Citizenship of India by BIRTH
PAN CYBPM5377B
Voter Id SHZ1980879
Employment Type SELF EMPLOYED
Is either of your parent (in case of
Y
minor)/spouse, a government servant?
Educational Qualification BETWEEN 8TH AND 9TH STANDARD
Are you eligible for Non-ECR category? N
Aadhaar Number 723132911558
Family Details
Father's Name AKADDES MAJHI
Mother's Name JHORNA MAJHI
Spouse's Name NAJMA MAJHI
Present Residential Address Details
3NO CHARAVIDYA, CHARAVIDYA, BASANTI, BARUIPUR, WEST
Address
BENGAL
PIN 743329
Police Station BASANTI
Mobile/Tel No. 7908995591
E-mail AJIJULMAJHI786@GMAIL.COM
Permanent Residential Address
3NO CHARAVIDYA, CHARAVIDYA, BASANTI, BARUIPUR, WEST
Address
BENGAL
PIN 743329
Police Station BASANTI
Mobile/Tel No. 7908995591
Emergency Contact Details
Name and Address MOJAHEHUR GAZI, TITKUMAR
Mobile/Tel No. 9134058215
Other Details
Payment Details
Mode of Payment UPI
Date 10/02/2024
Receipt/Reference No. CPADMYKBO9
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.PAN Card issued by the Income Tax Department
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 CARAVIDYA Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 10/02/2024 to sign)
Print Close
