22/11/2021, 17:51 Application Form
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 21-1008185429
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name PRAMILA OLIVIA D'SILVA
Date of Birth (DD/MM/YYYY) 29/01/1976
Validity Required NA
Place of Birth (Village/Town/City) MANGALORE
District DAKSHINA KANNADA
State/UT KARNATAKA
Region/Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type GOVERNMENT
Organisation name DEPARTMENT OF PUBLIC INSTRUCTION
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
Aadhaar Number 330494751265
Family Details
Father's Name JOHN PETER MONTEIRO
Mother's Name LUCY MONTEIRO
Spouse's Name AUSTIN D'SILVA
Present Residential Address Details
H NO 18-16 JILFUL VILLA PADAVU, KULSHEKAR, MANGALURU
Address
CITY, KARNATAKA
PIN 575005
Police Station MANGALORE EAST
Mobile/Tel No. 9164044664
E-mail CLARENCE.TAURO.1@GMAIL.COM
Permanent Residential Address
H NO 18-16 JILFUL VILLA PADAVU, KULSHEKAR, MANGALURU
Address
CITY, KARNATAKA
PIN 575005
Police Station MANGALORE EAST
Mobile/Tel No. 9164044664
Emergency Contact Details
Name and Address ASHNA D'SILVA
Mobile/Tel No. 9353640759
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J7096073
Date of Issue 10/06/2011
Date of Expiry 09/06/2021
Place of Issue BANGALORE
File Number BN4071299736111
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Aadhaar Card (Address Proof)
3.No Objection Certificate (NOC) as per Annexure G
Self Declaration
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/2
22/11/2021, 17:51 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 MANGALORE
Date 22/11/2021
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