5/7/24, 9:44 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 24-1005881999

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name SHIVASURIYA PRABHAKARAN

Date of Birth (DD/MM/YYYY) 07/09/2003

Validity Required NA

Place of Birth (Village/Town/City) MADURAI

District MADURAI CITY

State/UT TAMIL NADU

Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status SINGLE cannot sign.

Citizenship of India by BIRTH

Employment Type STUDENT

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

Family Details
Father's Name PRABAHARAN

Mother's Name INDRANI

Present Residential Address Details
4/24 BRINDVANAM 2ND STREET SRI NAGAR IYER,
Address
BUNGALOW ANAIYUR, MADURAI CITY, L/�@ C@

PIN 625017

Police Station D1-TALLAKULAM

Mobile/Tel No. 9361448497

E-mail [email protected]
Permanent Residential Address
4/24 BRINDVANAM 2ND STREET SRI NAGAR IYER,
Address
BUNGALOW ANAIYUR, MADURAI CITY, L/�@ C@

PIN 625017

Police Station D1-TALLAKULAM

Mobile/Tel No. 9361448497

Emergency Contact Details

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5/7/24, 9:44 PM View/Print Submitted Form

SHIVA SURIYA 4/24 BRINDVANAM 2ND STREET SRI NAGAR

Name and Address
IYER BUNGALOW ANAIYUR MADURAI

Mobile/Tel No. 9942795671

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.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognized educational board

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 VNR Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 07/05/2024 to sign)

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