10/2/23, 6:51 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 23-0018506820
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SUPRIYA DAS
Date of Birth (DD/MM/YYYY) 06/06/1975
Validity Required NA
Place of Birth (Village/Town/City) BHOPAL
District BHOPAL
State/UT MADHYA PRADESH
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender FEMALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.
Citizenship of India by BIRTH
PAN AQCPD2224R
Employment Type HOME MAKER
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
Visible Distinguishing Mark MOLE AT BACK RIGHT SIDE OF NECK
Aadhaar Number 332022829673
Family Details
Father's Name MANAS KUMAR CHAUDHURY
Mother's Name ANITA CHAUDHURY
Spouse's Name JOYDEB DAS
Present Residential Address Details
5/1,PARSI MOHALLA,CHAWNI, GPO, INDORE, INDORE,
Address
MADHYA PRADESH
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=23-0018506820 1/2
10/2/23, 6:51 PM View/Print Submitted Form
PIN 452001
Police Station SANYOGITAGANJ
Mobile/Tel No. 9926888200
E-mail SUPRIYAD435@GMAIL.COM
Permanent Residential Address
5/1,PARSI MOHALLA,CHAWNI, GPO, INDORE, INDORE,
Address
MADHYA PRADESH
PIN 452001
Police Station SANYOGITAGANJ
Mobile/Tel No. 9926888200
Emergency Contact Details
JOYDEB DAS, 5/1, PARSI MOHALLA, CHAWNI,GPO,
Name and Address
INDORE-452001
Mobile/Tel No. 9826023636 / 7898826815
E-mail JDDASS71@GMAIL.COM
Other Details
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 (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.
Place SUPRIYA DAS Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 02/10/2023 to sign)
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=23-0018506820 2/2
