8/13/22, 2:25 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 22-1009222303
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name MRIDULA BHATTACHARYA
Date of Birth (DD/MM/YYYY) 20/01/1966
Validity Required NA
Place of Birth (Village/Town/City) KAMALPUR
District DHALAI
State/UT TRIPURA
Region/Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN BEAPB1834E
Voter Id WB20138405522
Employment Type HOME MAKER
Is either of your parent (in case of minor)/spouse,
N
a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 918986513928
Family Details
Father's Name PORITOSH BHATTACHARYA
Mother's Name SANDHYA BHATTACHARYA
Spouse's Name TAPAN BHATTACHARJEE
Present Residential Address Details
279/1 BANGUR AVENUE,BL-B,FL-4B NIKITA APARTMENT, BANGUR,
Address
BIDHANNAGAR, WEST BENGAL
PIN 700055
Police Station LAKE TOWN PS
Mobile/Tel No. 9330785003
E-mail [email protected]
Permanent Residential Address
279/1 BANGUR AVENUE,BL-B,FL-4B NIKITA APARTMENT, BANGUR,
Address
BIDHANNAGAR, WEST BENGAL
PIN 700055
Police Station LAKE TOWN PS
Mobile/Tel No. 9330785003
Emergency Contact Details
TAPAN BHATTACHARJEE AND FLAT-4B,NIKITA APARTMENT,BLOCK-
Name and Address
B,279/1,BANGUR AVENUE, KOLKATA-700055
Mobile/Tel No. 9123095391
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number K6213449
Date of Issue 18/10/2012
Date of Expiry 17/10/2022
Place of Issue KOLKATA
File Number CA2061598306512
Other Details
Enclosures
1.PAN Card issued by the Income Tax Department
2.Aadhaar Card (Address Proof)

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8/13/22, 2:25 PM Application Form

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 KOLKATA
Date 13/08/2022

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