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PASSPORT APPLICATION FORM
Ministry of External Affairs, Government of India
Service Required
Application Reference Number - 25-1059197258
Applying For - FRESH
Type of Application - NORMAL
Type of Passport Booklet - NORMAL
Applicant's Details
Applicant's Name - RUSHDA HARMAIN
Date of Birth (DD/MM/YYYY) - 23/12/2015
Validity Required - NA
Place Of Birth (Village/Town/City) - SHIMOGA
District - SHIVAMOGGA
State/UT - KARNATAKA
Region/Country - INDIA
Gender - FEMALE
Marital Status - SINGLE
Citizenship of India by - BIRTH
Employment Type - STUDENT
Is either of your parent (in case of - N
minor)/spouse, a government
servant?
Educational Qualification - 7TH PASS OR LESS
Are you eligible for Non-ECR - N
category
Aadhaar Number - 737874272644
Family Details
Father Name - SAYEED AHMED SAYEED
Mother Name - GOUSIA BEGUM
Present Residential Address Details
Address - 2ND CROSS, RIGHT SIDE TIPPU NAGAR SHIMOGA, SHIMOGA,
SHIVAMOGGA, KARNATAKA
Pin - 577205
Police Station - TUNGANAGARA
Mobile/Tel No - 8904923836
E-mail - KOUTENSSMG94@GMAIL.COM
Emergency Contact Details
Name and Address - D/O SAYEED AHMED SAYEED 2ND CROSS, RIGHT SIDE TIPPU NAGAR
SHIMOGA
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Mobile/Tel No - 8904923836
Email ID - KOUTENSSMG94@GMAIL.COM
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Details of Previous/Current Diplomatic/Official Passport - N
Have you ever applied for passport, but not issued? - N
Other Details
Enclosures Details
1. Birth certificate issued by the Registrar of Births and Deaths or the Municipal Corporation or any other authority,
empowered under the Registration of Births and Deaths Act, 1969 (18 of 1969)
2. Aadhaar Card (Address Proof)
3. A declaration affirming the particular furnished in the application about the minor as per AnnexureC
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 - SHIMOGA
Date - 15/08/2025
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