11/6/24, 10:03 AM 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 24-1008047831

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 SRINIVASAN

Date of Birth (DD/MM/YYYY) 31/05/1980

Validity Required NA

Place of Birth (Village/Town/City) NAYANACHERUVU

District TIRUPATHUR

State/UT TAMIL NADU Signature/Left Hand Thumb Impression

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

Marital Status MARRIED

Citizenship of India by BIRTH

PAN BGCPS3612K

Voter Id CDB3191970

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

Aadhaar Number 882482318771

Family Details
Father's Name CHENDRAYAN

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11/6/24, 10:03 AM View/Print Submitted Form

Mother's Name LAKSHMI

Spouse's Name INDUMATHI

Present Residential Address Details
570A,NAYANACHERUVU,NATTRAMPALLI,TIRUPATTUR,
Address
NAYANACERUVU, TIRUPATHUR, TAMIL NADU

PIN 635852

Police Station NATRAMPALLI

Mobile/Tel No. 9443099231

E-mail [email protected]
Permanent Residential Address
570A,NAYANACHERUVU,NATTRAMPALLI,TIRUPATTUR,
Address
NAYANACERUVU, TIRUPATHUR, TAMIL NADU

PIN 635852

Police Station NATRAMPALLI

Mobile/Tel No. 9443099231

Emergency Contact Details
Name and Address NO 570A NAYANASERUVU, NATTRAMPALLI,TIRUPATHUR

Mobile/Tel No. 9789443983

E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J1463941

Date of Issue 06/10/2010

Date of Expiry 05/10/2020

Place of Issue CHENNAI

File Number MASC01955210

Details of Previous/Current Diplomatic/Official Passport
Passport Number J1463941

Date of Issue 06/10/2010

Date of Expiry 05/10/2020

Place of Issue CHENNAI

Other Details
Payment Details
Mode of Payment UPI

Date 25/06/2024

Receipt/Reference No. CPADXKDAS8

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

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

2.Electors Photo Identity Card (EPIC)

Self Declaration

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11/6/24, 10:03 AM View/Print Submitted Form

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 NATTRAAPALLI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 25/06/2024 to sign)

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