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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 24-0018019222
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name VAISHALI SHRIVASTAVA
Date of Birth (DD/MM/YYYY) 06/07/1995
Validity Required NA
Place of Birth (Village/Town/City) GWALIOR
District GWALIOR
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 LSSPS5969K
Employment Type GOVERNMENT
Organisation name GOVERNMENT
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 WHITE MOLE ON UPPER LIP
Aadhaar Number 930701868713
Family Details
Father's Name SUNIL KUMAR SHRIVASTAVA
Mother's Name BHAVANA SHRIVASTAVA
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Spouse's Name NEELESH SHRIVASTAVA
Present Residential Address Details
C/O NEELESH SHRIVASTAVA 00 CHANDRASHEKHAR
Address
WARD, BINA ETAWA, SAGAR, MADHYA PRADESH
PIN 470113
Police Station BINA
Mobile/Tel No. 9340282494 / 8878949549
E-mail VAISHALISH94@GMAIL.COM
Permanent Residential Address
RAJGHAT COLONY, DATIA, DATIA, MADHYA PRADESH,
Address
INDIA
PIN 475661
Police Station �H/��4O�2��� �
Mobile/Tel No. 9340282494 / 8878949549
Emergency Contact Details
Name and Address NEELESH SHRIVATAVA
Mobile/Tel No. 8878949549
E-mail NEELSHRIVASTAVA10@GMAIL.COM
Other Details
Payment Details
Mode of Payment UPI
Date 11/11/2024
Receipt/Reference No. CPAELFFJP8
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
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 DATIA Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 24/10/2024 to sign)
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