12/30/23, 12:08 PM Application Form
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 23-1016033103
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name DEEKSHITH ADEPU
Date of Birth (DD/MM/YYYY) 18/06/1995
Validity Required NA
Place of Birth (Village/Town/City) GODAVARIKHANI
District RAMAGUNDAM-PEDDAPALLI
State/UT TELANGANA
Region/Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN BPDPA2802R
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? N
Visible Distinguishing Mark A MOLE ON THE LEFT HAND ELBOW
Aadhaar Number 872833426714
Family Details
Father's Name SHANKAR ADEPU
Mother's Name SHARADHA ADEPU
Present Residential Address Details
NO 1, 1ST FLOOR, GANGAPARAMESHWARI LAYOUT, DEVANAHALLI,
Address
BENGALURU, KARNATAKA
PIN 562110
Police Station DEVANAHALLI
Mobile/Tel No. 9686245542
E-mail ADEPUDEEXITH44@GMAIL.COM
Permanent Residential Address
NO 1, 1ST FLOOR, GANGAPARAMESHWARI LAYOUT, DEVANAHALLI,
Address
BENGALURU, KARNATAKA
PIN 562110
Police Station DEVANAHALLI
Mobile/Tel No. 9686245542
Emergency Contact Details
ARSHIYA KAUSAR, NO 7/5, 2ND CROSS, SESHADRIPURAM, BANGALORE,
Name and Address
560020
Mobile/Tel No. 9108260198
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.
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12/30/23, 12:08 PM Application Form
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 BANGALORE
Date 30/12/2023
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