8/11/24, 9:30 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 24-0014058866
Applying For REISSUE
VALIDITY EXPIRED WITHIN 3
YEARS/DUE TO EXPIRE. , CHANGE
If Re-issue, specify reason(s)
IN EXISTING PERSONAL
PARTICULARS
If change in existing personal
APPEARANCE , SIGNATURE
particulars, specify
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name TUSHAR GUPTA
Date of Birth (DD/MM/YYYY) 10/09/2004
Validity Required NA Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Place of Birth (Village/Town/City) DELHI cannot sign.
District NORTH DELHI
State/UT DELHI
Region/Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
Employment Type STUDENT
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Family Details
Father's Name AJAY KUMAR GUPTA
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Mother's Name NIDHI GUPTA
Present Residential Address Details
57,TOP FLOOR,PREM NAGAR GALI NO.2,SHAKTI NAGAR,
Address
DELHI, NORTH DELHI, DELHI
PIN 110007
Police Station ROOP NAGAR
Mobile/Tel No. 9868877975
E-mail TUSHARGUPTA599@GMAIL.COM
Permanent Residential Address
57,TOP FLOOR,PREM NAGAR GALI NO.2,SHAKTI NAGAR,
Address
DELHI, NORTH DELHI, DELHI
PIN 110007
Police Station ROOP NAGAR
Mobile/Tel No. 9868877975
Emergency Contact Details
Name and Address MANAV GUPTA, SHAKTI NAGAR
Mobile/Tel No. 7042232269
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number R1763013
Date of Issue 01/08/2017
Date of Expiry 31/07/2022
Place of Issue DELHI
File Number DL2061276301217
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
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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 DELHI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 11/08/2024 to sign)
Print Close
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