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 24-0020851252
Applying For FRESH
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name PRAJAKTA RAJESH PATIL
Date of Birth (DD/MM/YYYY) 02/11/1998
Validity Required NA
Place of Birth (Village/Town/City) BARAMATI
District PUNE RURAL
State/UT MAHARASHTRA
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
Employment Type OTHERS
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
Aadhaar Number 589289799256
Family Details
Father's Name VIJAYSINH ANANDRAO EJAGAR
Mother's Name KALPANA VIJAYSINH EJAGAR
Spouse's Name RAJESH POPAT PATIL
Present Residential Address Details
FLAT-409, A BUILDING, MAJESTIQUE NEST, FURSUNGI,
Address
PUNE CITY, MAHARASHTRA
PIN 412308
Police Station HADAPSAR
Mobile/Tel No. 9607231001
E-mail DRPRAJAKTAPATIL1001@GMAIL.COM
Permanent Residential Address
LANDE WASTI, DEWADE, DEWADE, SOLAPUR RURAL,
Address
MAHARASHTRA, INDIA
PIN 413304
Police Station KARKAMB
Mobile/Tel No. 9607231001
Emergency Contact Details
Name and Address RAJESH PATIL
Mobile/Tel No. 9970671001
E-mail PATILRAJESH1001@GMAIL.COM
Other Details
Payment Details
Mode of Payment UPI
Date 17/12/2024
Receipt/Reference No. CPAEOTAUU6
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognized educational board
2.Electricity Bill
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 FURSUNGI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 17/12/2024 to sign)
