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 23-1006319369

Applying For REISSUE

VALIDITY EXPIRED MORE THAN 3

If Re-issue, specify reason(s)
YEARS AGO

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details

Applicant's Name MISBA FIRDOSE

Date of Birth (DD/MM/YYYY) 17/05/2010

Validity Required NA

Place of Birth (Village/Town/City) TUMKUR

District TUMAKURU

State/UT KARNATAKA Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender FEMALE

Marital Status SINGLE

Citizenship of India by BIRTH

Employment Type STUDENT

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification BETWEEN 8TH AND 9TH STANDARD

Are you eligible for Non-ECR category? N

Visible Distinguishing Mark MOLE ON FACE

Aadhaar Number 653859705726

Family Details

Father's Name MAHABOOB BASHA AMEER JAN

Mother's Name SHABIN UNNISA

Mother/Legal guardian's File/Passport Number J7972204

Present Residential Address Details

Address 12TH CROSS PH COLONY, TUMKUR, TUMAKURU, KARNATAKA

PIN 572101

Police Station THILAK PARK

Mobile/Tel No. 9740108269

E-mail [email protected]
Permanent Residential Address

Address 12TH CROSS PH COLONY, TUMKUR, TUMAKURU, KARNATAKA

PIN 572101

Police Station THILAK PARK

Mobile/Tel No. 9740108269

Emergency Contact Details

Name and Address MOHAMMED SHOAIB 12TH CROSS PH COLONY

Mobile/Tel No. 7019597845

Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport

Passport Number L9344349

Date of Issue 15/05/2014

Date of Expiry 14/05/2019

Place of Issue BANGLORE

File Number BN1067675601314

Other Details
Payment Details

Mode of Payment UPI

Date 21/05/2023

Receipt/Reference No. CPACTNBXJ3

Amount Received (Rs.) 1000.00 (ONE THOUSAND ONLY)

Enclosures

1.Aadhaar Card/E-Aadhaar

2.Aadhaar Card (Address Proof)

3.A declaration affirming the particulars furnished in the application about the minor as per Annexure C
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.

Signature/Left Hand Thumb Impression of

Place TUMKUR Applicant (If applicant is minor, either parent
to sign)
Date 21/05/2023
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