12/17/23, 5:11 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 23-1015419777
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name REKHA SIDRAM BELLUNDAGI
Date of Birth (DD/MM/YYYY) 01/01/1989
Validity Required NA
Place of Birth (Village/Town/City) MAKHANAPUR
District VIJAYAPURA
State/UT KARNATAKA
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 GNWPB4122H
Employment Type HOME MAKER
Is either of your parent (in case of
Y
minor)/spouse, a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 415742820206
Family Details
Father's Name SHIDARAMAPPA SHAKAREPPA BELLUNDAGI
Mother's Name SHARADA SIDRAM BELLUNDAGI
Spouse's Name SACHIN HAKKE
Present Residential Address Details
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12/17/23, 5:11 PM View/Print Submitted Form
Address MAKHANAPUR, MAKHANAPUR, VIJAYAPURA, KARNATAKA
PIN 586119
Police Station ADARSH NAGAR
Mobile/Tel No. 9686527344
E-mail REKHABELLUNDAGI@GMAIL.COM
Permanent Residential Address
Address MAKHANAPUR, MAKHANAPUR, VIJAYAPURA, KARNATAKA
PIN 586119
Police Station ADARSH NAGAR
Mobile/Tel No. 9686527344
Emergency Contact Details
Name and Address SACHIN , AMBIGAR GALLI, AT POST AUJ(MANDRUP)
Mobile/Tel No. 9923593746
E-mail SACHINHAKKE8@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.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.
Place MAKHANAPUR Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 17/12/2023 to sign)
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