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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 24-0015343598

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 NARESH KUMAR SHARMA

Date of Birth (DD/MM/YYYY) 30/06/1982

Validity Required NA

Place of Birth (Village/Town/City) BALESAR SATTAN

District JODHPUR RURAL

State/UT RAJASTHAN Signature/Left Hand Thumb Impression


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

Marital Status SINGLE

Citizenship of India by BIRTH

PAN DQGPK7671L

Voter Id HHF1857127

Employment Type SELF EMPLOYED

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

Visible Distinguishing Mark HURT MARK ON LEFT WRIST

Aadhaar Number 347227576081

Family Details

Father's Name MADAN LAL

Mother's Name BASANTI DEVI


Present Residential Address Details
149 FSS COLONY, BALESAR SATTAN, JODHPUR RURAL,
Address
RAJASTHAN

PIN 342023

Police Station BALESAR

Mobile/Tel No. 8290170677

E-mail [email protected]
Permanent Residential Address

149 FSS COLONY, BALESAR SATTAN, JODHPUR RURAL,


Address
RAJASTHAN

PIN 342023

Police Station BALESAR

Mobile/Tel No. 8290170677


Emergency Contact Details

Name and Address DR ASHOK KUMAR

Mobile/Tel No. 8290746775

E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport

Passport Number L3470035

Date of Issue 01/12/2014

Date of Expiry 30/11/2016

Place of Issue LONDON

File Number GBRLP2009214


Other Details
Have you ever returned to India on Emergency Certificate (EC)?

EC No. X0924548

Date of Issue 29/08/2023

Date of return to India (DD/MM/YYYY) 31/08/2023

Issuing Authority EMBASSY OF INDIA/SPAIN - MADRID

Region/Country from where travelled on


SPAIN - MADRID
EC/deported/repatriated

Reason for issuing EC/deported/ repatriated VOLUNTEER RETURN


Payment Details

Mode of Payment UPI

Date 09/09/2024

Receipt/Reference No. CPAEEUVEJ8

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)


Enclosures

1.PAN Card issued by the Income Tax Department

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 JODHPUR Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 06/09/2024 to sign)

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