10/4/2018 View/Print Submitted Form
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 18-0015364702
Applying For REISSUE
VALIDITY EXPIRED WITHIN 3
If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name TASNEEM IDRIS ICECREAMWALA
Date of Birth (DD/MM/YYYY) 28/04/1975
Validity Required NA
Place of Birth (Village/Town/City) DAHOD
District DAHOD
State/UT GUJARAT Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Country INDIA cannot sign.
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN ACGPI4637K
Employment Type HOME MAKER
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? N
Aadhaar Number 527973032115
Family Details
Father's Name MUSTAFA ATTARWALA
Mother's Name NAFISA ATTARWALA
Spouse's Name IDRIS EBRAHIM ICECREAMWALA
Present Residential Address Details
Address G/2, SWISS VIEW CHS, K T VILLAGE, DIWANMAN, VASAI
WEST, VASAI, PALGHAR, MAHARASHTRA
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=18-0015364702 1/2
10/4/2018 View/Print Submitted Form
PIN 401202
Mobile/Tel No. 9892242521
E-mail IDRISHAMID52@GMAIL.COM
Permanent Residential Address
G/2, SWISS VIEW CHS, K T VILLAGE, DIWANMAN, VASAI
Address
WEST, VASAI, PALGHAR, MAHARASHTRA
PIN 401202
Mobile/Tel No. 9892242521
Emergency Contact Details
Name and Address IDRIS ICECREAMWALA
Mobile/Tel No. 9224700151
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number H3686522
Date of Issue 19/03/2009
Date of Expiry 18/03/2019
Place of Issue THANE
File Number THNN00129809
Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)
Fee amount in (Rs)
If paid by Demand Draft(DD), provide the following details
DD Issue Date (dd/mm/yyyy)
DD Expiry Date (dd/mm/yyyy)
Bank Name
Branch
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Aadhaar Card/e-Aadhar containing the 12 digit Aadhaar number issued by the Unique Identification Authority of India(UIDAI)
Self Declaration
I owe allegiance to the sovereignty, unity and 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 and I affirm that the information given by
me in this form and the enclosures is true and I am solely responsible for its accuracy, and 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.
Place VASAI WEST Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 04/10/2018 to sign)
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=18-0015364702 2/2
