10/2/23, 6:51 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 23-0018506820

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name SUPRIYA DAS

Date of Birth (DD/MM/YYYY) 06/06/1975

Validity Required NA

Place of Birth (Village/Town/City) BHOPAL

District BHOPAL

State/UT MADHYA 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 AQCPD2224R

Employment Type HOME MAKER

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

Visible Distinguishing Mark MOLE AT BACK RIGHT SIDE OF NECK

Aadhaar Number 332022829673

Family Details
Father's Name MANAS KUMAR CHAUDHURY

Mother's Name ANITA CHAUDHURY

Spouse's Name JOYDEB DAS

Present Residential Address Details
5/1,PARSI MOHALLA,CHAWNI, GPO, INDORE, INDORE,
Address
MADHYA PRADESH

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10/2/23, 6:51 PM View/Print Submitted Form

PIN 452001

Police Station SANYOGITAGANJ

Mobile/Tel No. 9926888200

E-mail [email protected]
Permanent Residential Address
5/1,PARSI MOHALLA,CHAWNI, GPO, INDORE, INDORE,
Address
MADHYA PRADESH

PIN 452001

Police Station SANYOGITAGANJ

Mobile/Tel No. 9926888200

Emergency Contact Details
JOYDEB DAS, 5/1, PARSI MOHALLA, CHAWNI,GPO,
Name and Address
INDORE-452001

Mobile/Tel No. 9826023636 / 7898826815

E-mail [email protected]
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
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 SUPRIYA DAS Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 02/10/2023 to sign)

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