28/09/2024, 22:29 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 24-0016695016
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name MOHD HARUN
Date of Birth (DD/MM/YYYY) 10/05/1993
Validity Required NA
Place of Birth (Village/Town/City) BHANGA
District UDHAM SINGH NAGAR
State/UT UTTARAKHAND
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.
Citizenship of India by BIRTH
PAN ARNPH5576J
Employment Type SELF EMPLOYED
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 985098131772
Family Details
Father's Name MOHD FARUK
Mother's Name SABRA
Spouse's Name SHAKEELA
Present Residential Address Details
WARD NO 11, BHANGA, UDHAM SINGH NAGAR,
Address
UTTARAKHAND
PIN 263148
Police Station PULBHATTA
Mobile/Tel No. 8077128154
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28/09/2024, 22:29 View/Print Submitted Form
E-mail [email protected]
Permanent Residential Address
WARD NO 11, BHANGA, UDHAM SINGH NAGAR,
Address
UTTARAKHAND
PIN 263148
Police Station PULBHATTA
Mobile/Tel No. 8077128154
Emergency Contact Details
Name and Address MOHD FARUK
Mobile/Tel No. 8411801976
Other Details
Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)
Fee amount in (Rs)
If paid by Demand Draft(DD), provide the following details
DD Issue Date (dd/mm/yyyy)
DD Expiry Date (dd/mm/yyyy)
Bank Name
Branch
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.
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 KICHHA Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 28/09/2024 to sign)
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