11/4/22, 3:37 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 22-0018854772
 
Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name VIVEK KUMAR SRIVASTAVA

Date of Birth (DD/MM/YYYY) 05/10/1980

Validity Required NA   

Place of Birth (Village/Town/City) LALKUAN

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 BJZPS2802K

Voter Id ZVC0003723

Employment Type PRIVATE

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

MINOR CUT MARK ABOVE THE

Visible Distinguishing Mark
RIGHT EYE

Aadhaar Number 258660072774

Family Details
Father's Name LATE GYAN CHANDRA SRIVASTAVA

Mother's Name LATE SMT VIMLA SRIVASTAVA

Spouse's Name SARIKA BHATNAGAR

Present Residential Address Details

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11/4/22, 3:37 PM View/Print Submitted Form

Address VILLAGE
CHUKATINAVALCOLONYDEORIA,UDHAMSINGHNAGAR,
CHUKATI DEORIA, UDHAM SINGH NAGAR, UTTARAKHAND

PIN 263148

Police Station KICHHA

Mobile/Tel No. 9411994186 / 7017432690

E-mail [email protected]
Permanent Residential Address
VILLAGE
Address CHUKATINAVALCOLONYDEORIA,UDHAMSINGHNAGAR,
CHUKATI DEORIA, UDHAM SINGH NAGAR, UTTARAKHAND

PIN 263148

Police Station KICHHA

Mobile/Tel No. 9411994186 / 7017432690

Emergency Contact Details
Name and Address AYUSH PRADHAN

Mobile/Tel No. 7505627477

E-mail [email protected]
Other Details
Payment Details
Mode of Payment Debit/Credit Card

Date 04/11/2022

Receipt/Reference No. CPACEMUHQ8

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.

CHUKATI
Place Signature/Left Hand Thumb Impression of
DEORIA
Applicant
(If applicant is minor, either parent
to sign)
Date 04/11/2022

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