PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 23-0020192308
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED MORE THAN 3 YEARS AGO
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name NOORJAHAN SALIM SHAIKH
Date of Birth (DD/MM/YYYY) 18/07/1952
Validity Required NA
Place of Birth (Village/Town/City) JANEFAL AURANGABAD MS
District MUMBAI
State/UT MAHARASHTRA
Region/Country INDIA
Gender FEMALE
Marital Status WIDOW/ WIDOWER
Citizenship of India by BIRTH
PAN COLPS6997H
Voter Id TOS5238522
Employment Type NOT EMPLOYED
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 7TH PASS OR LESS
Are you eligible for Non-ECR category? Y
Aadhaar Number 981879217729
Family Details
Father's Name GULAB KHAIRU SHAIKH
Mother's Name SHAHZADI GULAB SHAIKH
Spouse's Name SALIM NIZAM SHAIKH
Present Residential Address Details
RAJIV GANDHI NAGAR DARGA ROAD SONAPUR BHANDUP, WEST, MUMBAI,
Address
MAHARASHTRA
PIN 400078
Police Station BHANDUP
Mobile/Tel No. 8169156699
E-mail [email protected]
Permanent Residential Address
RAJIV GANDHI NAGAR DARGA ROAD SONAPUR BHANDUP, WEST, MUMBAI,
Address
MAHARASHTRA
PIN 400078
Police Station BHANDUP
Mobile/Tel No. 8169156699
Emergency Contact Details
NOORJAHAN SALIM SHAIKH, RAJIV GANDHI NAGAR DARGA ROAD SONAPUR
Name and Address
BHANDUP
Mobile/Tel No. 8169156699
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J1683460
Date of Issue 30/07/2010
Date of Expiry 29/07/2020
Place of Issue MUMBAI
File Number BOMB01487510
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Aadhaar Card (Address Proof)
3.Affidavit stating how and where the Passport got lost/ damaged as per Annexure F
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 BHANDUP
Date 02/11/2023
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