5/23/24, 5:20 PM Application Form
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 24-1006638461
Applying For FRESH
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name PRIYANKA DESHMUKH
Date of Birth (DD/MM/YYYY) 12/08/1999
Validity Required NA
Place of Birth (Village/Town/City) BANKURA
District BANKURA
State/UT WEST BENGAL
Region/Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN EEFPD8153A
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark CUT MARK IN RIGHT HAND
Aadhaar Number 576018309247
Family Details
Father's Name BIDYUT BIKASH DESHMUKH
Mother's Name MITHU DESHMUKH
Present Residential Address Details
Address VILL-LACHIPUR, LACHAIPUR, LACHIPUR, BANKURA, WEST BENGAL
PIN 722101
Police Station BANKURA
Mobile/Tel No. 7362952619
E-mail DESHMUKHPRIYANKA384@GMAIL.COM
Permanent Residential Address
Address VILL-LACHIPUR, LACHAIPUR, LACHIPUR, BANKURA, WEST BENGAL
PIN 722101
Police Station BANKURA
Mobile/Tel No. 7362952619
Emergency Contact Details
Name and Address BIDYUT BIKASH DESHMUKH
Mobile/Tel No. 9735134868
E-mail AYAN.CVRCE@GMAIL.COM
Other Details
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 KOLKATA
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/2
5/23/24, 5:20 PM Application Form
Date 23/05/2024
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