11/6/24, 10:03 AM 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 24-1008047831
Applying For REISSUE
VALIDITY EXPIRED MORE THAN 3
If Re-issue, specify reason(s)
YEARS AGO
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SRINIVASAN
Date of Birth (DD/MM/YYYY) 31/05/1980
Validity Required NA
Place of Birth (Village/Town/City) NAYANACHERUVU
District TIRUPATHUR
State/UT TAMIL NADU Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN BGCPS3612K
Voter Id CDB3191970
Employment Type SELF EMPLOYED
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 882482318771
Family Details
Father's Name CHENDRAYAN
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Mother's Name LAKSHMI
Spouse's Name INDUMATHI
Present Residential Address Details
570A,NAYANACHERUVU,NATTRAMPALLI,TIRUPATTUR,
Address
NAYANACERUVU, TIRUPATHUR, TAMIL NADU
PIN 635852
Police Station NATRAMPALLI
Mobile/Tel No. 9443099231
E-mail [email protected]
Permanent Residential Address
570A,NAYANACHERUVU,NATTRAMPALLI,TIRUPATTUR,
Address
NAYANACERUVU, TIRUPATHUR, TAMIL NADU
PIN 635852
Police Station NATRAMPALLI
Mobile/Tel No. 9443099231
Emergency Contact Details
Name and Address NO 570A NAYANASERUVU, NATTRAMPALLI,TIRUPATHUR
Mobile/Tel No. 9789443983
E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J1463941
Date of Issue 06/10/2010
Date of Expiry 05/10/2020
Place of Issue CHENNAI
File Number MASC01955210
Details of Previous/Current Diplomatic/Official Passport
Passport Number J1463941
Date of Issue 06/10/2010
Date of Expiry 05/10/2020
Place of Issue CHENNAI
Other Details
Payment Details
Mode of Payment UPI
Date 25/06/2024
Receipt/Reference No. CPADXKDAS8
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognized educational board
2.Electors Photo Identity Card (EPIC)
Self Declaration
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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 NATTRAAPALLI Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 25/06/2024 to sign)
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