Validity Required NA
Place 1:26
6/24/24, of Birth
PM (Village/Town/City) PEN Application Form
District RAIGAD
Region/Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN IBXPP0400F
Voter Id XCY8277527
Employment Type SELF EMPLOYED
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? N
Aadhaar Number 976377379340
Family Details
Father's Name RAJKUMAR MUKHLAL PRAJAPATI
Mother's Name RAGANI RAJKUMAR PRAJAPATI
Present Residential Address Details
LOKAMANYA HOUSING SOCIETY, NEAR CARMEL SCHOOL, PEN, RAIGAD,
Address
MAHARASHTRA
PIN 402107
Police Station PEN
Mobile/Tel No. 7052390085
E-mail DHIRAJBOSSBGMI@GMAIL.COM
Emergency Contact Details
Name and Address DHIRAJ PRAJAPATI, LOKMANYA HOUSING SOCIETY, PEN, RAIGAD
Mobile/Tel No. 7052390085
E-mail DHIRAJBOSSBGMI@GMAIL.COM
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 PEN
Date 24/06/2024
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/1
