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 25-0003109008
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name MEHULKUMAR MALI
Date of Birth (DD/MM/YYYY) 27/01/2005
Validity Required NA
Place of Birth (Village/Town/City) BHABHAR
District BANASKANTHA
State/UT GUJARAT
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status SINGLE cannot sign.
Citizenship of India by BIRTH
PAN ILFPM9669K
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 237673519115
Family Details
Father's Name ASHOKBHAI MALI
Mother's Name MANIBEN MALI
Present Residential Address Details
AMBIKA NAGAR,BHABHAR, BHABHAR JUNA,BANASKANTHA,
Address
BHABHAR, BANASKANTHA, GUJARAT
PIN 385320
Police Station BHABHAR
Mobile/Tel No. 8160244845
E-mail MALIMEHUL372@GMAIL.COM
Permanent Residential Address
AMBIKA NAGAR,BHABHAR, BHABHAR JUNA,BANASKANTHA,
Address
BHABHAR, BANASKANTHA, GUJARAT
PIN 385320
Police Station BHABHAR
Mobile/Tel No. 8160244845
Emergency Contact Details
Name and Address SANJAY, BHABHAR AMBIKA NAGAR
Mobile/Tel No. 9737137385
E-mail MALISANJAYMALI6053@GMAIL.COM
Other Details
Payment Details
Mode of Payment UPI
Date 23/02/2025
Receipt/Reference No. CPAEVRAWY6
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.Permanent Account Number Card issued by the Income-tax Department having the date of birth of the applicant
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 GUJARAT Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 23/02/2025 to sign)
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