11/4/22, 3:37 PM 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 22-0018854772
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name VIVEK KUMAR SRIVASTAVA
Date of Birth (DD/MM/YYYY) 05/10/1980
Validity Required NA
Place of Birth (Village/Town/City) LALKUAN
District UDHAM SINGH NAGAR
State/UT UTTARAKHAND
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 BJZPS2802K
Voter Id ZVC0003723
Employment Type PRIVATE
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
MINOR CUT MARK ABOVE THE
Visible Distinguishing Mark
RIGHT EYE
Aadhaar Number 258660072774
Family Details
Father's Name LATE GYAN CHANDRA SRIVASTAVA
Mother's Name LATE SMT VIMLA SRIVASTAVA
Spouse's Name SARIKA BHATNAGAR
Present Residential Address Details
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=22-0018854772 1/2
11/4/22, 3:37 PM View/Print Submitted Form
Address VILLAGE
CHUKATINAVALCOLONYDEORIA,UDHAMSINGHNAGAR,
CHUKATI DEORIA, UDHAM SINGH NAGAR, UTTARAKHAND
PIN 263148
Police Station KICHHA
Mobile/Tel No. 9411994186 / 7017432690
E-mail VIVEKSRIVASTAVA5108@GMAIL.COM
Permanent Residential Address
VILLAGE
Address CHUKATINAVALCOLONYDEORIA,UDHAMSINGHNAGAR,
CHUKATI DEORIA, UDHAM SINGH NAGAR, UTTARAKHAND
PIN 263148
Police Station KICHHA
Mobile/Tel No. 9411994186 / 7017432690
Emergency Contact Details
Name and Address AYUSH PRADHAN
Mobile/Tel No. 7505627477
E-mail AYUSHPRADHAN0123@GMAIL.COM
Other Details
Payment Details
Mode of Payment Debit/Credit Card
Date 04/11/2022
Receipt/Reference No. CPACEMUHQ8
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.Aadhaar Card/E-Aadhaar
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.
CHUKATI
Place Signature/Left Hand Thumb Impression of
DEORIA
Applicant
(If applicant is minor, either parent
to sign)
Date 04/11/2022
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=22-0018854772 2/2
