Generated at: 2025-04-13 23:27:46

HAJ COMMITTEE OF INDIA

ONLINE HAJ APPLICATION FORM FOR HAJ – 2025 (C.E.) 1446 (Hijri)

240830202931223
1 .Category General Cover No. KAF-1399-2-0
2. No. of Persons 2 No. of Infants 0
3. Name of Cover Head IYUB KHAN Embarkation Preference 1 /
2 : BANGALORE /
BANGALORE

4. Applicant’s Details (As per International Passport)

Passport Number S0504120 Place of Issue BENGALURU Date of Issue 05-03-2018

Date of Expiry 04-03-2028 Date of Birth 20-04-1963 Place of Birth Anekal
Surname Given Name IYUB KHAN Father’s Name Habeeb ulla khan
Gender Male Mother’s Name Zehra khatoon Spouse’s Name MUBEEN TAJ
Marital Status MARRIED Blood Group A+ Qualification PRIMARY
Occupation RETIRED Aadhaar No. 4905-9733***** PAN No. ALEPA*****
Companion Name Companion Relation NA

5. Health Details

Detail of Co-Morbidity Not Applicable Pregnancy Status NA

6. Present Residential Address

No 860 indilabelle road 2nd main chowdeshwari nagar atti belle anekal tq Bengaluru
Address Pincode 562107
562107
State Karnataka District Bengaluru urban
Mobile Number 7892288213 WhatsApp No / Mobile No.2 7892288213 Email Id [email protected]

7. Details of Nominee of Applicant

Name Shoaib khan Mobile Number : 7892288213

Father’s /Husband’s Name Iyub khan
Relationship SON
#860, indlabele 2nd main road chowdeshwari nagar attibele Bangalore Karnataka
Address Pincode 562107
562107
Signature / Thumb impression
State Karnataka District Bengaluru rural
of Nominee

8. Name of Mehram with Relation (applicable for female pilgrims only)

Name Relationship: NA
Signature / Thumb impression
Passport No.
of Mehram

9. Bank Account Details

Name of Account Holder SHOAIB KHAN A Bank Name STATE BANK OF INDIA
Account No. 20201949199 IFSC Code SBIN0000814

10. Are you a permissible Repeater Mehram? NO

11. Do you want to perform ADAHI (Qurbani)? NO
12. Opting JHOFA Meeqat (Only for Shia Pilgrims)? NO
13. Are you NRI? NO
14. Are you a person with benchmark disability/disabilities, who cannot travel alone as certified by medical authorities? NO
Indicate the nature of your disability
Companion Name
Companion Relation

• I hereby undertake to abide by all the guidelines, including health protocol, age and travel restrictions, etc. issued by the Kingdom of Saudi Arabia and the Government of India/Haj
Committee of India in view of CoVID-19 pandemic. I agree to travel to the Embarkation Point allotted to me and am ready to pay all the charges on all accounts. I am also willing to go
through the RT-PCR test and quarantine period as specified in the protocol and guidelines
• I am aware of the tentative cost of Haj 2025, which may vary due to operational or functional reasons.
• I certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee
All entries in the above HAF have been checked and found to be in order. Certified that the applicant is eligible to register for Haj-2025 (CE). 1446 (Hijri)
 SOLEMN DECLARATION AND UNDERTAKING

For General Category

I, Mr./Mrs./Miss IYUB KHAN S/o./W/o./D/o. Habeeb ulla khan, an Indian citizen, do hereby solemnly affirm and declare as under:
1. I am aware that, as per Government of India policy, a person can perform Haj only "Once in a Lifetime" through Haj Committee of India (HCol).
2. I have never performed Haj through HCol in the past, and hence I am eligible to apply for Haj - 2025 (Hijri - 1446). I am aware that repeaters are not
eligible for Haj - 2025 (Hijri - 1446) and if it is detected at any stage that I have already performed Haj through HCoI, my seat shall be cancelled and the
entire amount deposited by me shall be forfeited.
3. I have read and understood thoroughly the Guidelines for Haj - 2025 (Hijri - 1446), particularly with reference to eligibility, cost, payments and
confirmation, cancellation, refunds, embarkation points, vaccination and health requirements before flight, baggage, flight, and accommodation in the
Kingdom of Saudi Arabia, and I undertake to abide by the same.
4. I hereby authorize HCol to send SMS to my mobile phone number, even if I am on the DND registry.
5. The particulars given by me in HAF, Solemn Declaration and Undertaking are true and correct to the best of my knowledge. I do hereby affirm and
declare that in the event I have suppressed material information or given a false / incorrect declaration / undertaking, HCoI shall forfeit the amount
deposited by me and I shall be liable for prosecution.
6. I am aware that HCol reserves the right to change the Embarkation Point opted by me. In such a case, I shall abide by the decision of HCol and shall
not show any resentment, whatsoever, against the decision of HCoI.
7. I am ready to pay Visa Fees, as levied by the KSA Haj Authorities for endorsement of my Haj Visa.
8. I/We understand that the HCoI works without any profit motive and does not attract the provisions of the Consumer Protection Act, 2019.
9. I/we understand that the Courts of Greater Mumbai only shall have jurisdiction in all matters of dispute. Further, the Supreme Court of India, in its
April 16, 2013 Judgement, barred all Courts and Authorities from interfering with the Haj Process.
10. I/We understand that my/our candidature shall be cancelled if I am/we are found carrying khas-khas, viagra-tablets, sexual oil and creams, synthetic
capore, cystone, khammera, gutkha, khaini, gul, peppermint, or narcotics in any form. Besides, I/we will be penalized for carrying banned items as per the
prevailing regulations of Saudi Arabia, and I/we will be liable for deportation to India from KSA at any stage of Haj.
11. I hereby agree that the Rubat and metro transport facilities will be subject to the terms and conditions of KSA, and that if this is not possible, I will be
obligated to pay charges for the services provided to me.
12. I do not have any criminal prosecutions pending against me and there is no Court Order prohibiting me/us to travel abroad exists.
13. I am medically fit to perform the Haj pilgrimage and do not have any contagious diseases.
14. I understand that accommodation in Madinah is subject to availability, I may be allotted accommodation in Markazia or Non Markazia as per the
availability. I will accept the accommodation provided to me, which is approved by the authorities in KSA.

Date:___________________________

Place:___________________________

______________________________________________________
Signature / Thumb impression of the applicant.
 PASSPORT DECLARATION FORM
(Only for Provisionally Selected Pilgrims)

To,
The Chief Executive Officer
Haj Committee of India,
Haj House, HAJ - 2025
7-A, M.R.A. Marg (Palton Road),
Mumbai - 400 001.

Cover Number: KAF-1399-2-0

Details of Pilgrims
Sr. No. Information to be filled by Pilgrim
(as per Valid Indian International Passport)

1 Name of the Pilgrim IYUB KHAN

2 Date of Birth (DD/MM/YYYY) 20-04-1963

3 Gender (Male/Female/Other) Male

4 Passport Number S0504120

Date of Issue of Passport

5 05-03-2018
(On or before 09-09-2024)

Date of Expiry of Passport

6 04-03-2028
(On or after 15-01-2026)

7 Whether it is a valid machine- readable passport (Yes/No)

8 Whether Passport is damaged/torn/wet/loosened, in any form. (Yes/No)

Whether at least two continuous blank pages are available in your

9
passport (Yes/No)

(i) I, the undersigned, hereby certify that the above information is correct to the best of my knowledge. I declare that the passport mentioned above is in
my possession and custody. The passport is not physically damaged/torn/wet/loosened and all pagesin the Passport are intact.
(ii) Further, whenever I travel abroad on this passport, I will inform to the Haj Committee of India (HCoI)and/or concerned SHC till my submission of
original passportwith the concerned SHC.
(iii) I also assure that whenever the HCoI require the passport, I will promptly submit it to the respective SHC.

_________________________________
Place:
Signature/Thumb impression
Date:
IYUB KHAN
 Generated at: 2025-04-13 23:27:46

HAJ COMMITTEE OF INDIA

ONLINE HAJ APPLICATION FORM FOR HAJ – 2025 (C.E.) 1446 (Hijri)
Adult Pilgrim Detail : 2

240830202931223
1 .Category General Cover No. KAF-1399-2-0
2. No. of Persons 2 No. of Infants 0
3. Name of Cover Head IYUB KHAN Embarkation Preference 1 /
2 : BANGALORE /
BANGALORE

4. Applicant’s Details (As per International Passport)

Passport Number C1459387 Place of Issue BENGALURU Date of Issue 28-08-2024

Date of Expiry 27-08-2034 Date of Birth 22-07-1973 Place of Birth AttiBelle, Karnataka
Surname Given Name MUBEEN TAJ Father’s Name ABDUL LATEEF
Gender Female Mother’s Name AMEERUNISA Spouse’s Name AYUB KHAN
Marital Status MARRIED Blood Group B+ Qualification PRIMARY
Occupation HOUSE WIFE Aadhaar No. 2422-7448***** PAN No. CTOPM*****
Companion Name Companion Relation NA

5. Health Details

Detail of Co-Morbidity Not Applicable Pregnancy Status No

6. Present Residential Address

No 860 indilabelle road 2nd main chowdeshwari nagar atti belle anekal tq Bengaluru
Address Pincode 562107
562107
State Karnataka District Bengaluru urban
Mobile Number 7892288213 WhatsApp No / Mobile No.2 7892288213 Email Id [email protected]

7. Details of Nominee of Applicant

Name Shoaib khan Mobile Number : 7892288213

Father’s /Husband’s Name Iyub khan
Relationship SON
#860, indlabele 2nd main road chowdeshwari nagar attibele Bangalore Karnataka
Address Pincode 562107
562107
Signature / Thumb impression
State Karnataka District Bengaluru rural
of Nominee

8. Name of Mehram with Relation (applicable for female pilgrims only)

Name IYUB KHAN Relationship: HUSBAND

Signature / Thumb impression
Passport No. S0504120
of Mehram

9. Bank Account Details

Name of Account Holder SHOAIB KHAN A Bank Name STATE BANK OF INDIA
Account No. 20201949199 IFSC Code SBIN0000814

10. Are you a permissible Repeater Mehram? NO

11. Do you want to perform ADAHI (Qurbani)? NO
12. Opting JHOFA Meeqat (Only for Shia Pilgrims)? NO
13. Are you NRI? NO
14. Are you a person with benchmark disability/disabilities, who cannot travel alone as certified by medical authorities? NO
Indicate the nature of your disability
Companion Name
Companion Relation

• I hereby undertake to abide by all the guidelines, including health protocol, age and travel restrictions, etc. issued by the Kingdom of Saudi Arabia and the Government of India/Haj
Committee of India in view of CoVID-19 pandemic. I agree to travel to the Embarkation Point allotted to me and am ready to pay all the charges on all accounts. I am also willing to go
through the RT-PCR test and quarantine period as specified in the protocol and guidelines
• I am aware of the tentative cost of Haj 2025, which may vary due to operational or functional reasons.
• I certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee
All entries in the above HAF have been checked and found to be in order. Certified that the applicant is eligible to register for Haj-2025 (CE). 1446 (Hijri)
 SOLEMN DECLARATION AND UNDERTAKING

For General Category

I, Mr./Mrs./Miss MUBEEN TAJ S/o./W/o./D/o. ABDUL LATEEF, an Indian citizen, do hereby solemnly affirm and declare as under:
1. I am aware that, as per Government of India policy, a person can perform Haj only "Once in a Lifetime" through Haj Committee of India (HCol).
2. I have never performed Haj through HCol in the past, and hence I am eligible to apply for Haj - 2025 (Hijri - 1446). I am aware that repeaters are not
eligible for Haj - 2025 (Hijri - 1446) and if it is detected at any stage that I have already performed Haj through HCoI, my seat shall be cancelled and the
entire amount deposited by me shall be forfeited.
3. I have read and understood thoroughly the Guidelines for Haj - 2025 (Hijri - 1446), particularly with reference to eligibility, cost, payments and
confirmation, cancellation, refunds, embarkation points, vaccination and health requirements before flight, baggage, flight, and accommodation in the
Kingdom of Saudi Arabia, and I undertake to abide by the same.
4. I hereby authorize HCol to send SMS to my mobile phone number, even if I am on the DND registry.
5. The particulars given by me in HAF, Solemn Declaration and Undertaking are true and correct to the best of my knowledge. I do hereby affirm and
declare that in the event I have suppressed material information or given a false / incorrect declaration / undertaking, HCoI shall forfeit the amount
deposited by me and I shall be liable for prosecution.
6. I am aware that HCol reserves the right to change the Embarkation Point opted by me. In such a case, I shall abide by the decision of HCol and shall
not show any resentment, whatsoever, against the decision of HCoI.
7. I am ready to pay Visa Fees, as levied by the KSA Haj Authorities for endorsement of my Haj Visa.
8. I/We understand that the HCoI works without any profit motive and does not attract the provisions of the Consumer Protection Act, 2019.
9. I/we understand that the Courts of Greater Mumbai only shall have jurisdiction in all matters of dispute. Further, the Supreme Court of India, in its
April 16, 2013 Judgement, barred all Courts and Authorities from interfering with the Haj Process.
10. I/We understand that my/our candidature shall be cancelled if I am/we are found carrying khas-khas, viagra-tablets, sexual oil and creams, synthetic
capore, cystone, khammera, gutkha, khaini, gul, peppermint, or narcotics in any form. Besides, I/we will be penalized for carrying banned items as per the
prevailing regulations of Saudi Arabia, and I/we will be liable for deportation to India from KSA at any stage of Haj.
11. I hereby agree that the Rubat and metro transport facilities will be subject to the terms and conditions of KSA, and that if this is not possible, I will be
obligated to pay charges for the services provided to me.
12. I do not have any criminal prosecutions pending against me and there is no Court Order prohibiting me/us to travel abroad exists.
13. I am medically fit to perform the Haj pilgrimage and do not have any contagious diseases.
14. I understand that accommodation in Madinah is subject to availability, I may be allotted accommodation in Markazia or Non Markazia as per the
availability. I will accept the accommodation provided to me, which is approved by the authorities in KSA.

Date:___________________________

Place:___________________________

______________________________________________________
Signature / Thumb impression of the applicant.
 PASSPORT DECLARATION FORM
(Only for Provisionally Selected Pilgrims)

To,
The Chief Executive Officer
Haj Committee of India,
Haj House, HAJ - 2025
7-A, M.R.A. Marg (Palton Road),
Mumbai - 400 001.

Cover Number: KAF-1399-2-0

Details of Pilgrims
Sr. No. Information to be filled by Pilgrim
(as per Valid Indian International Passport)

1 Name of the Pilgrim MUBEEN TAJ

2 Date of Birth (DD/MM/YYYY) 22-07-1973

3 Gender (Male/Female/Other) Female

4 Passport Number C1459387

Date of Issue of Passport

5 28-08-2024
(On or before 09-09-2024)

Date of Expiry of Passport

6 27-08-2034
(On or after 15-01-2026)

7 Whether it is a valid machine- readable passport (Yes/No)

8 Whether Passport is damaged/torn/wet/loosened, in any form. (Yes/No)

Whether at least two continuous blank pages are available in your

9
passport (Yes/No)

(i) I, the undersigned, hereby certify that the above information is correct to the best of my knowledge. I declare that the passport mentioned above is in
my possession and custody. The passport is not physically damaged/torn/wet/loosened and all pagesin the Passport are intact.
(ii) Further, whenever I travel abroad on this passport, I will inform to the Haj Committee of India (HCoI)and/or concerned SHC till my submission of
original passportwith the concerned SHC.
(iii) I also assure that whenever the HCoI require the passport, I will promptly submit it to the respective SHC.

_________________________________
Place:
Signature/Thumb impression
Date:
MUBEEN TAJ