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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 24-0002588962
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 JUMBO
Applicant Details
Applicant's Name RAJ KAMAL CHOUDHARY
Date of Birth (DD/MM/YYYY) 15/01/1988
Validity Required NA
Place of Birth (Village/Town/City) BOKARO
District BOKARO
State/UT JHARKHAND Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN APPPC0757E
Voter Id GPV0072926
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
CUT MARK IN THE LEFT SIDE
Visible Distinguishing Mark
FOREHEAD
Aadhaar Number 257237785021
Family Details
Father's Name RAM CHANDRA CHOUDHARY
Mother's Name INDU CHOUDHARY
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Spouse's Name ROSHANI KUMARI
Present Residential Address Details
FLAT NO A/301,ELYSIAN CITY APARTMENTS, NANDUA
Address
ASTHAN,CHAS, BOKARO, JHARKHAND
PIN 827013
Police Station CHAS
Mobile/Tel No. 9954441660
E-mail RAJKAMAL1414@GMAIL.COM
Emergency Contact Details
RAVI RAMAN & FLAT NO B/ 403,ELYSIAN CITY
Name and Address APARTMENTS, NANDUA ASTHAN, NEAR ASHA ITI
COLLEGE, CHAS
Mobile/Tel No. 7004666834
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M4872258
Date of Issue 30/12/2014
Date of Expiry 29/12/2024
Place of Issue GUWAHATI
File Number GU1060058059613
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.PAN Card issued by the Income Tax Department
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.
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Place BOKARO Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 10/02/2024 to sign)
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