4/4/23, 4:04 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 23-0006245406
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name POOJA CHAURASIYA
Date of Birth (DD/MM/YYYY) 18/05/1999
Validity Required NA
Place of Birth (Village/Town/City) MUMBAI
District THANE CITY
State/UT MAHARASHTRA
Region/Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN BYTPC1160K
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse,
N
a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? N
Visible Distinguishing Mark NONE
Aadhaar Number 650236153763
Family Details
Father's Name SHRIRAM CHAURASIYA
Mother's Name PREMA CHAURASIYA
Present Residential Address Details
ROOM NO.2 KISHOR NIWASH SANGEETAWADI DOMBIVALI E, DOMBIVALI, THANE
Address
CITY, MAHARASHTRA
PIN 421201
Police Station DOMBIWALI
Mobile/Tel No. 8369043816 / 8369043816
E-mail CHAURASIYAPOOJA891@GMAIL.COM
Permanent Residential Address
ROOM NO.2 KISHOR NIWASH SANGEETAWADI DOMBIVALI E, DOMBIVALI, THANE
Address
CITY, MAHARASHTRA
PIN 421201
Police Station DOMBIWALI
Mobile/Tel No. 8369043816 / 8369043816
Emergency Contact Details
Name and Address SATISH
Mobile/Tel No. 08898987433 / 8898987433
E-mail SATISH.SHAW.90044@GMAIL.COM
Other Details
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

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4/4/23, 4:04 PM Application Form
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
Date 04/04/2023

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