24/02/2025, 08:08 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 25-0002622682
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name PIYUSH KUMAR
Date of Birth (DD/MM/YYYY) 25/01/2007
Validity Required NA
Place of Birth (Village/Town/City) JAMSHEDPUR
District SARAIKELA KHARSAWAN
Region/Country INDIA
Gender MALE
Signature/Left Hand Thumb Impression
Marital Status SINGLE of Illiterate Applicant and Minors who
Citizenship of India by BIRTH cannot sign.
PAN PUGPK3167P
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
Aadhaar Number 440017632768
Family Details
Father's Name ARVIND KUMAR
Mother's Name SUREKHA DEVI
Present Residential Address Details
YASHODHA NAGAR ROAD NO 7 NEAR KALI MANDIR,
Address
ADITYAPUR, SARAIKELA KHARSAWAN, JHARKHAND
PIN 831013
Police Station R.I.T SUB
Mobile/Tel No. 9508030583
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24/02/2025, 08:08 View/Print Submitted Form
E-mail PIYUSHKR2501@GMAIL.COM
Permanent Residential Address
YASHODHA NAGAR ROAD NO 7 NEAR KALI MANDIR,
Address
ADITYAPUR, SARAIKELA KHARSAWAN, JHARKHAND
PIN 831013
Police Station R.I.T SUB
Mobile/Tel No. 9508030583
Emergency Contact Details
Name and Address ATISH KUMAR , ROAD NO.7,ADITYAPUR-2
Mobile/Tel No. 9835074026
Other Details
Payment Details
Mode of Payment UPI
Date 14/02/2025
Receipt/Reference No. CPAEUTEWB9
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.
SERAIKELA-
Place Signature/Left Hand Thumb Impression of
KHARSAWAN
Applicant (If applicant is minor, either parent
Date 14/02/2025 to sign)
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