PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 24-1014869493
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name MADHU A V
Date of Birth (DD/MM/YYYY) 08/07/1987
Validity Required NA
Place of Birth (Village/Town/City) CHANNAPATNA
District RAMANAGAR
State/UT KARNATAKA
Region/Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN CEIPM6874E
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Family Details
Father's Name VEEREGOWDA
Mother's Name THAYAMMA
Spouse's Name SUMALATHA AKKURU RAJA GURU
Present Residential Address Details
AGRAHARA VALAGEREHALLI, CHANNAPATNA, RAMANAGAR,
Address
KARNATAKA
PIN 562160
Police Station CHANNAPATANA RURAL
Mobile/Tel No. 9980719819
E-mail MADHUAV87@GMAIL.COM
Permanent Residential Address
AGRAHARA VALAGEREHALLI, CHANNAPATNA, RAMANAGAR,
Address
KARNATAKA
PIN 562160
Police Station CHANNAPATANA RURAL
Mobile/Tel No. 9980719819
Emergency Contact Details
Name and Address SUMALATHA A R
Mobile/Tel No. 9844580472
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 CHANNAPATNA
Date 07/12/2024
