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    saurav.lokdhun

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    23 views2 pages

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    2/8/24, 11:53 PM 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 24-0002190006

    Applying For FRESH

    Type of Application TATKAAL

    Type of Passport Booklet NORMAL


    Applicant Details
    Applicant's Name DIPALI SHARMA

    Date of Birth (DD/MM/YYYY) 19/09/2001

    Validity Required NA

    Place of Birth (Village/Town/City) HARDOI

    District HARDOI

    State/UT UTTAR PRADESH

    Region/Country INDIA
    Signature/Left Hand Thumb Impression
    Gender FEMALE of Illiterate Applicant and Minors who
    Marital Status MARRIED cannot sign.

    Citizenship of India by BIRTH

    PAN HYSPS1917R

    Employment Type NOT 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? N

    Visible Distinguishing Mark MOLE BELOW RIGHT EAR

    Aadhaar Number 610590325527

    Family Details
    Father's Name SURENDRA KUMAR

    Mother's Name PINKY SHARMA

    Spouse's Name SAURAV KUMAR TRIVEDI


    Present Residential Address Details
    RZ 24 STREET NO 3 SYNDICATE ENCLAVE RAGHU NAGAR,
    Address
    NEW DELHI, SOUTH WEST DELHI, DELHI

    https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-0002190006 1/2
    2/8/24, 11:53 PM View/Print Submitted Form

    PIN 110045

    Police Station SAGAR PUR

    Mobile/Tel No. 6306214742

    E-mail DIPALISHARMA4742@GMAIL.COM
    Permanent Residential Address
    RZ 24 STREET NO 3 SYNDICATE ENCLAVE RAGHU NAGAR,
    Address
    NEW DELHI, SOUTH WEST DELHI, DELHI

    PIN 110045

    Police Station SAGAR PUR

    Mobile/Tel No. 6306214742


    Emergency Contact Details
    Name and Address SAURAV KUAMAR TRIVEDI

    Mobile/Tel No. 8178426400

    E-mail SAURAVTRIVEDI12999@GMAIL.COM
    Other Details
    Payment Details
    Mode of Payment UPI

    Date 05/02/2024

    Receipt/Reference No. CPADMOOVQ3

    Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)


    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 NEW DELHI Signature/Left Hand Thumb Impression of


    Applicant (If applicant is minor, either parent
    Date 04/02/2024 to sign)

    https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-0002190006 2/2

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