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File Number (For Office Use Only)

Ministry of External Affairs, Government of India

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 - 25-0061332162 Please paste your
Number unsigned recent
Applying For - REISSUE color photograph
of size 4.5cm *
If Re-issue, specify - CHANGE IN EXISTING PERSONAL PARTICULARS 3.5cm.
reason(s)
If change in existing - ADDRESS , DELETE ECR
personal particulars,
specify
Type of Application - NORMAL
Type of Passport - NORMAL
Booklet
Signature/Left Hand Thumb
Impression of Illiterate Applicant and
Applicant Details Minors who cannot sign.
Applicant's Name - AJAY SINGH
Date of Birth - 01/01/2001
(DD/MM/YYYY)
Validity Required - NA
Place Of Birth - RANIA
(Village/Town/City)
District - SIRSA
State/UT - HARYANA
Region/Country - INDIA
Gender - MALE
Marital Status - SINGLE
Citizenship of India by - BIRTH
Employment Type - PRIVATE
Is either of your parent - N
(in case of
minor)/spouse, a
government servant?
Educational - 10TH PASS AND ABOVE
Qualification
Are you eligible for - Y
Non-ECR category
Aadhaar Number - 637848777999

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8/12/25, 10:52 AM ViewPrintApplicationReceipt

Family Details
Father Name - MAKHAN SINGH
Mother Name - BIMLA RANI

Present Residential Address Details:

Address - HOUSE NO 77/C,MASITA WALA MOHALLA, WARD NO 14,RANIA (137),
SIRSA, HARYANA
Pin - 125076
Police Station - RANIA
Mobile/Tel No - 9053292327
Email - [email protected]

Permanent Residential Address Details

Address - HOUSE NO 77/C,MASITA WALA MOHALLA, WARD NO 14,RANIA (137),
SIRSA, HARYANA
Pin - 125076
Police Station - RANIA
Mobile/Tel No - 9053292327

EmergencyContactDetails:
Name and Address - MAKHAN SINGH
Mobile/Tel No. - 9671541976

Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number - B9917130
Date of Issue - 01/03/2024
Date of Expiry - 28/02/2034
Place of Issue - JAIPUR
File Number - JP01C4092510023

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:

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8/12/25, 10:52 AM ViewPrintApplicationReceipt

1. Aadhaar Card (Address Proof)2. Transfer or school leaving or matriculation certificate issued by the recognised school
last attended or recognised educational board having the date of birth of the applicant

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 - RANIA
Signature/Left Hand Thumb Impression
of Applicant (If applicant is minor, either
Date - 10/08/2025
parent to sign)

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