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 25-0001037466
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 SUSHILA
Date of Birth (DD/MM/YYYY) 08/03/1975
Validity Required NA
Place of Birth (Village/Town/City) NARWANA
District HISAR
State/UT HARYANA Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type HOME MAKER
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
Family Details
Father's Name GANGA SINGH
Mother's Name RAJI
Spouse's Name SURENDER SINGH
Present Residential Address Details
Address 2675 SECTOR 4, HISAR, HISAR, HARYANA
PIN 125001
Police Station CITY HISAR
Mobile/Tel No. 9991667018
E-mail DALALGUL@[Link]
Permanent Residential Address
Address 2675 SECTOR 4, HISAR, HISAR, HARYANA
PIN 125001
Police Station CITY HISAR
Mobile/Tel No. 9991667018
Emergency Contact Details
Name and Address SURENDER
Mobile/Tel No. 9813267018
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number G2977793
Date of Issue 03/05/2007
Date of Expiry 02/05/2017
Place of Issue CHANDIGARH
Other Details
Payment Details
Mode of Payment UPI
Date 18/01/2025
Receipt/Reference No. CPAESCGGH8
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
[Link] Photo Identity Card (EPIC) issued by the Election Commission of India
[Link] Photo Identity Card (EPIC)
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 GURGAON Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 17/01/2025 to sign)
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