29/07/2024, 23:40 Application Form
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 24-0013258732
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application TATKAAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name VIBHA PREMASHISH SHRIVASTAVA
Date of Birth (DD/MM/YYYY) 07/02/1971
Validity Required NA
Place of Birth (Village/Town/City) DARBHANGA
District DARBHANGA
State/UT BIHAR
Region/Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN BBMPS1513G
Employment Type NOT 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? Y
Aadhaar Number 458051885844
Family Details
Father's Name SUSHIL KUMAR VERMA
Mother's Name MANJULATA SUSHIL KUMAR VERMA
Spouse's Name PREMASHISH MADAN SHRIVASTAVA
Present Residential Address Details
SR.NO.77/1, FLAT NO.101, POWER BOULEVARD, MUNDHWA, PUNE
Address
CITY, MAHARASHTRA
PIN 411036
Police Station MUNDHWA
Mobile/Tel No. 8806063494
E-mail VIBHAS0702@GMAIL.COM
Permanent Residential Address
SR.NO.77/1, FLAT NO.101, POWER BOULEVARD, MUNDHWA, PUNE
Address
CITY, MAHARASHTRA
PIN 411036
Police Station MUNDHWA
Mobile/Tel No. 8806063494
Emergency Contact Details
Name and Address PREMASHISH SHRIVASTAVA
Mobile/Tel No. 8806063494
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M3687334
Date of Issue 18/11/2014
Date of Expiry 17/11/2024
Place of Issue DUBAI
File Number UAED17734014
Other Details
Enclosures
1.PAN Card issued by the Income Tax Department
2.Aadhaar Card (Address Proof)
Self Declaration
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29/07/2024, 23:40 Application Form
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 PUNE
Date 29/07/2024
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