Application Form https://portal2.passportindia.gov.in/AppOnlineProject/secure/Applicant...

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-1013509803
Applying For REISSUE
If Re-issue, specify reason(s) CHANGE IN EXISTING PERSONAL PARTICULARS
If change in existing personal particulars, specify OTHER
If other, specify NEED MORE VALIDITY
Type of Application TATKAAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name MOHAMMED KAKKOT KALLERY
Date of Birth (DD/MM/YYYY) 08/11/1987
Validity Required NA
Place of Birth (Village/Town/City) MAHE
District MAHE
State/UT PUDUCHERRY
Region/Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 694017087319
Family Details
Father's Name NAZIMUDHEEN NELLIYIL
Mother's Name AYSHA KAKKOT KALLERY
Spouse's Name SUHAIMA MOHAMMED
Present Residential Address Details
Address KALLERY HOUSE,PARAKKAL, MAHE PO, MAHE, PUDUCHERRY
PIN 673310
Police Station PALLOOR
Mobile/Tel No. 9400533112
E-mail [email protected]
Permanent Residential Address
Address KALLERY HOUSE,PARAKKAL, MAHE PO, MAHE, PUDUCHERRY
PIN 673310
Police Station PALLOOR
Mobile/Tel No. 9400533112
Emergency Contact Details
Name and Address SUHAIMA MOHAMMED
Mobile/Tel No. 9400533112
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number Z4683640
Date of Issue 01/04/2018
Date of Expiry 31/03/2028
Place of Issue DUBAI
File Number UAED06384818
Other Details

1 of 2 11/6/2024, 11:00 AM
Application Form https://portal2.passportindia.gov.in/AppOnlineProject/secure/Applicant...

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 MAHE
Date 06/11/2024

2 of 2 11/6/2024, 11:00 AM