02/11/2024, 11:11 Application Form
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 24-0018366392
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SHIFABANU SIPAI
Date of Birth (DD/MM/YYYY) 27/12/2003
Validity Required NA
Place of Birth (Village/Town/City) SIDHPUR
District PATAN
State/UT GUJARAT
Region/Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN TEEPS6777B
Employment Type OTHERS
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 285633073798
Family Details
Father's Name IRFANHUSEN SIPAI
Mother's Name NASIMBANU SIPAI
Present Residential Address Details
NAVAVAS,VISNAGER NO MAHOLLO,SIDHPUR, SIDHPUR, PATAN,
Address
GUJARAT
PIN 384151
Police Station SIDHPUR
Mobile/Tel No. 9106877067
E-mail MODIKHUSI3@GMAIL.COM
Permanent Residential Address
NAVAVAS,VISNAGER NO MAHOLLO,SIDHPUR, SIDHPUR, PATAN,
Address
GUJARAT
PIN 384151
Police Station SIDHPUR
Mobile/Tel No. 9106877067
Emergency Contact Details
Name and Address SIPAI IRFANHUSEN
Mobile/Tel No. 7041584961
Other Details
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 SIDHPUR
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02/11/2024, 11:11 Application Form
Date 02/11/2024
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 2/2
