7/31/23, 6:55 AM 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 23-0012412170
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 NORMAL
Applicant Details
Applicant's Name JIGNA VIJAY SHAH
Date of Birth (DD/MM/YYYY) 16/12/1974
Validity Required NA
Place of Birth (Village/Town/City) JASHVANGADH
District SABARKANTHA
State/UT GUJARAT Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN BHSPS5754D
Voter Id DWJ1642057
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? N
Visible Distinguishing Mark SCAR ON RIGHT EYELID
Aadhaar Number 826806015821
Family Details
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Father's Name BHARAT KUMAR VITHALDAS MEHTA
Mother's Name LILAVATI BHARATKUMAR MEHTA
Spouse's Name VIJAY RAJENDRA SHAH
Present Residential Address Details
602/KHATRI APARTMENT JAYANTISHUKLA ROAD, MALAD
Address
WEST, MUMBAI, MAHARASHTRA
PIN 400064
Police Station MALAD
Mobile/Tel No. 9819718158
E-mail SHAHJIGNA1612@GMAIL.COM
Permanent Residential Address
602/KHATRI APARTMENT JAYANTISHUKLA ROAD, MALAD
Address
WEST, MUMBAI, MAHARASHTRA
PIN 400064
Police Station MALAD
Mobile/Tel No. 9819718158
Emergency Contact Details
Name and Address NIKISH KITAWAT 402 KHATRI APT
Mobile/Tel No. 9920378793
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number L2500401
Date of Issue 07/06/2013
Date of Expiry 06/06/2023
Place of Issue MUMBAI
File Number BO1060965764613
Other Details
Payment Details
Mode of Payment Debit/Credit Card
Date 05/07/2023
Receipt/Reference No. CPACWPXRL2
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
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
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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 MUMBAI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 03/07/2023 to sign)
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