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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 24-0018869524
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name ABHISHEK KUMAR
Date of Birth (DD/MM/YYYY) 26/05/1994
Validity Required NA
Place of Birth (Village/Town/City) SITAMARHI
District SITAMARHI
State/UT BIHAR
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.
Citizenship of India by BIRTH
PAN DEXPK8371G
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Employment Type PRIVATE
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
SURGERY MARK ON LEFT UPPER
Visible Distinguishing Mark
HIB
Aadhaar Number 663510615418
Family Details
Father's Name RAGHUNANDAN CHOUDHARY
Mother's Name LALITA DEVI
Spouse's Name SHALINI KUMARI
Present Residential Address Details
WARD NO-02, SHASTRI NAGAR, NAGAR PANCHAYAT
Address
DUMRA, DUMRA, SITAMARHI, BIHAR
PIN 843301
Police Station DUMRA
Mobile/Tel No. 7903509297
E-mail ABHISHEKKR1126@GMAIL.COM
Permanent Residential Address
WARD NO-02, SHASTRI NAGAR, NAGAR PANCHAYAT
Address
DUMRA, DUMRA, SITAMARHI, BIHAR
PIN 843301
Police Station DUMRA
Mobile/Tel No. 7903509297
Emergency Contact Details
Name and Address SHALINI KUMARI, SITAMARHI, BIHAR
Mobile/Tel No. 7004046623
Other Details
Payment Details
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Mode of Payment Debit/Credit Card
Date 11/11/2024
Receipt/Reference No. CPAELEFZG9
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.
Place SITAMARHI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 11/11/2024 to sign)
Print Close
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