12/5/23, 1:13 PM View/Print Submitted Form
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 23-0017182422
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name JITENDRA KUMAR PRAJAPAT
Date of Birth (DD/MM/YYYY) 03/07/1998
Validity Required NA
Place of Birth (Village/Town/City) NAYAN
District JAIPUR RURAL
State/UT RAJASTHAN
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 EUAPP9197P
Employment Type STUDENT
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? Y
Aadhaar Number 250746996302
Family Details
Father's Name BABU LAL PRAJAPAT
Mother's Name SAMPATA DEVI PRAJAPAT
Present Residential Address Details
WARD NO- 13,KUMHARO KA MOHALLA, NAYAN, JAIPUR
Address
RURAL, RAJASTHAN
PIN 303601
Police Station AMARSAR
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=23-0017182422 1/2
12/5/23, 1:13 PM View/Print Submitted Form
Mobile/Tel No. 8233882449
E-mail JITUPRAJAPAT0101@GMAIL.COM
Permanent Residential Address
WARD NO- 13,KUMHARO KA MOHALLA, NAYAN, JAIPUR
Address
RURAL, RAJASTHAN
PIN 303601
Police Station AMARSAR
Mobile/Tel No. 8233882449
Emergency Contact Details
Name and Address RAJU PRAJAPAT
Mobile/Tel No. 9783465850
Other Details
Payment Details
Mode of Payment Challan
Date 10/11/2023
Receipt/Reference No. 298504284
Amount Received (Rs.) 2000.00 (TWO THOUSAND ONLY)
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Driving Licenses (valid and within the jurisdiction of state of submission of application)
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 JAIPUR RURAL Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 11/09/2023 to sign)
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=23-0017182422 2/2
