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 25-0004370868
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name MANOHAR JEYARAJ
Date of Birth (DD/MM/YYYY) 18/05/1965
Validity Required NA
Place of Birth (Village/Town/City) VALLIYUR
District TIRUNELVELI CITY
State/UT TAMIL NADU
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 AKOPM7648A
Voter Id WIC3835782
Employment Type PRIVATE
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark MOLE ON CHEEK NEAR LEFT EAR
Aadhaar Number 483712822679
Family Details
Father's Name KUMARASAMY RAJAIYA JEYARAJ
Mother's Name J NACHATHIRAM
Spouse's Name JEBA PONMALAR MANOHAR
Present Residential Address Details
2302,GLORIA REGENCY ANANTAM,KALYAN SHIL ROAD,
Address
DOMBIVALI EAST, THANE CITY, MAHARASHTRA
PIN 421203
Police Station MANPADA
Mobile/Tel No. 9819931170
E-mail JAMANOHAR@GMAIL.COM
Permanent Residential Address
2302,GLORIA REGENCY ANANTAM,KALYAN SHIL ROAD,
Address
DOMBIVALI EAST, THANE CITY, MAHARASHTRA
PIN 421203
Police Station MANPADA
Mobile/Tel No. 9819931170
Emergency Contact Details
SOLOMON JEYARAJ MANOHAR,2302,GLORIA REGENCY
Name and Address ANANTAM,KALYAN SHIL RD,VICO NAKA, DOMBIVALI (EAST)
421203
Mobile/Tel No. 9167240707
E-mail SOLOMONJMANOHAR@GMAIL.COM
Other Details
Payment Details
Mode of Payment UPI
Date 28/03/2025
Receipt/Reference No. CPAEZAGME3
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.Permanent Account Number Card issued by the Income-tax Department having the date of birth of the applicant
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 DOMBIVALI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 28/03/2025 to sign)
