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This document is a passport application form for an individual named Jaybodh Jha. It contains personal details like name, date of birth, address, family details, employment and education information. The applicant is providing these details along with self-declaration and necessary documents to apply for an Indian passport as a normal citizen applying for the first time. He is affirming that the information provided is true and he is not suppressing any details. The application includes payment receipt details and the types of documents submitted in support of the application.

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RAMESH LAISHETTY
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
53 views

View - Print Submitted Form Passport

This document is a passport application form for an individual named Jaybodh Jha. It contains personal details like name, date of birth, address, family details, employment and education information. The applicant is providing these details along with self-declaration and necessary documents to apply for an Indian passport as a normal citizen applying for the first time. He is affirming that the information provided is true and he is not suppressing any details. The application includes payment receipt details and the types of documents submitted in support of the application.

Uploaded by

RAMESH LAISHETTY
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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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 21-0006933060
 
Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name JAYBODH JHA

Date of Birth (DD/MM/YYYY) 08/01/1969

Validity Required NA   

Place of Birth (Village/Town/City) SUBHASH KESO

District DARBHANGA

State/UT BIHAR

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 ALFPJ7385R

Employment Type PRIVATE

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification 7TH PASS OR LESS

Are you eligible for Non-ECR category? Y

Aadhaar Number 569770550974

Family Details
Father's Name BABUPRASAD JHA

Spouse's Name URMILADEVI JHA


Present Residential Address Details
RAJIV GANDHI NAGAR,TADALI,KAMATGHAR,BHIWANDI,
Address
THANE, THANE RURAL, MAHARASHTRA

PIN 421305

Police Station BHIWANDI TALUKA


Mobile/Tel No. 7385436335

E-mail [email protected]
Permanent Residential Address
RAJIV GANDHI NAGAR,TADALI,KAMATGHAR,BHIWANDI,
Address
THANE, THANE RURAL, MAHARASHTRA

PIN 421305

Police Station BHIWANDI TALUKA

Mobile/Tel No. 7385436335


Emergency Contact Details
C-14 PLOT NO 24 GANRAYA CHSL CHARKOP KANDIVALI
Name and Address
WEST

Mobile/Tel No. 8692853778


Other Details
Payment Details
Mode of Payment UPI

Date 11/08/2021

Receipt/Reference No. CPAAZHPRH7

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


Enclosures
1.Aadhaar Card/E-Aadhaar

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 BHIWANDI Signature/Left Hand Thumb Impression of


Applicant
(If applicant is minor, either parent
Date 11/08/2021 to sign)

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