2/12/25, 8:19 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 25-1001788097

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name JESSICA REICHEL V

Previous Name1 ANNAPOORANI M

Date of Birth (DD/MM/YYYY) 15/11/1983

Validity Required NA

Place of Birth (Village/Town/City) CHENNAI

District CHENNAI

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

Citizenship of India by BIRTH

PAN BYLPJ1120L

Voter Id LMG330861

Employment Type HOME MAKER

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 808478739553

Family Details
Father's Name MANI P

Mother's Name DHANALAKSHMI M

Spouse's Name SATHISH V

Present Residential Address Details
17/1 JANDRAVAR STREET KALADIPET TIRUVOTTIYUR,
Address
CHENNAI, CHENNAI, L /�@ C@

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2/12/25, 8:19 PM View/Print Submitted Form

PIN 600019

Police Station H-8 THIRUVOTRIYUR

Mobile/Tel No. 9884990456

E-mail [email protected]
Permanent Residential Address
17/1 JANDRAVAR STREET KALADIPET TIRUVOTTIYUR,
Address
CHENNAI, CHENNAI, L /�@ C@

PIN 600019

Police Station H-8 THIRUVOTRIYUR

Mobile/Tel No. 9884990456

Emergency Contact Details
JESSICA REICHEL 17/1 JANDRAVAR STREET
Name and Address
KALADIPETTIRUVOTTIYUR

Mobile/Tel No. 9894990456

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

Date 12/02/2025

Receipt/Reference No. CPAEUNQBH6

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

Enclosures
1.Driving License issued by the Transport department of concerned state Government

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 CHENNAI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 10/02/2025 to sign)

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