2/14/25, 9:26 AM Application Form
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 25-1002233381
Applying For REISSUE
VALIDITY EXPIRED MORE THAN 3 YEARS AGO , CHANGE IN EXISTING
If Re-issue, specify reason(s)
PERSONAL PARTICULARS
If change in existing personal particulars, specify ADDRESS
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SARBUDEEN KANI MOHAMED
Date of Birth (DD/MM/YYYY) 13/01/1989
Validity Required NA
Place of Birth (Village/Town/City) VEMBARPATTI
District MADURAI CITY
State/UT TAMIL NADU
Region/Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN FREPS0227R
Employment Type SELF EMPLOYED
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 IN MY LEFT HAND WRIST
Aadhaar Number 577417515732
Family Details
Father's Name KANI MOHAMED K
Mother's Name AMINAA BEEVI K
Spouse's Name ANEETHA BANU S
Present Residential Address Details
Address 6/33H, PAPA NAGAR, KARUNGALAKUDY, MADURAI RURAL, TAMIL NADU
PIN 625101
Police Station KOTTAMPATTI
Mobile/Tel No. 7418418403
E-mail SARBU1318@GMAIL.COM
Permanent Residential Address
Address 6/33H, PAPA NAGAR, KARUNGALAKUDY, MADURAI RURAL, TAMIL NADU
PIN 625101
Police Station KOTTAMPATTI
Mobile/Tel No. 7418418403
Emergency Contact Details
Name and Address MOHAMED ALI
Mobile/Tel No. 9789799142
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J5667803
Date of Issue 09/03/2011
Date of Expiry 08/03/2021
Place of Issue MADURAI
File Number MDUA00108811
Other Details
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2/14/25, 9:26 AM Application Form
Enclosures
1.PAN Card issued by the Income Tax Department
2.Aadhaar Card (Address Proof)
3.Affidavit stating how and where the Passport got lost/ damaged as per Annexure F
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 KARUNGALAKUDY
Date 20/02/2025
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