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Uploaded by

Yagesh Gupta
Copyright
© © All Rights Reserved
Available Formats
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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 24-0017529304

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name RAAVI GUPTA

Date of Birth (DD/MM/YYYY) 11/03/1998

Validity Required NA

Place of Birth (Village/Town/City) DELHI

District GHAZIABAD

State/UT UTTAR PRADESH

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

Citizenship of India by BIRTH

PAN BWEPG0578A

Voter Id XPD9335720

Employment Type PRIVATE

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 899102780618

Family Details
Father's Name AJESH GUPTA

Mother's Name HEMLATA GUPTA


Present Residential Address Details
G-1210 UNINAV HEIGHTS RAJ NAGAR EXTENSION,
Address
GHAZIABAD, GHAZIABAD, UTTAR PRADESH

PIN 201017

Police Station NANDGRAM

Mobile/Tel No. 9319526068 / 9212920610

E-mail [email protected]
Permanent Residential Address
G-1210 UNINAV HEIGHTS RAJ NAGAR EXTENSION,
Address
GHAZIABAD, GHAZIABAD, UTTAR PRADESH

PIN 201017

Police Station NANDGRAM

Mobile/Tel No. 9319526068 / 9212920610


Emergency Contact Details
VAARI GUPTA AND G-1210 UNINAV HEIGHTS, RAJ NAGAR
Name and Address
EXTENSION , GHAZIABAD , UTTAR PRADESH

Mobile/Tel No. 9212920610 / 9873247010

E-mail [email protected]
Other Details
Payment Details
Mode of Payment UPI

Date 30/12/2024

Receipt/Reference No. CPAEQBANI9

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


Enclosures
1.Election Photo Identity Card (EPIC) issued by the Election Commission of India

2.Electors Photo Identity Card (EPIC)


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 GHAZIABAD Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 15/10/2024 to sign)

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