PASSPORT APPLICATION FORM Government of INDIA,Ministry of External Affairs

Service Required Application Reference Number Applying For Type of Application Type of Passport Booklet Applicant Details Applicant's Name Date of Birth (DD/MM/YYYY) Place of Birth (Village/Town/City) District State/UT Country Gender Marital Status Citizenship of India by Employment Type Is either of your parent (in case of minor)/ spouse, a government servant? Educational Qualification Are you eligible for Non-ECR category? Visible Distinguishing Mark Family Details Father's Name Mother's Name Present Address Details Residing Since(MM/YYYY) Address PIN Mobile/Tel No Email First Reference Name And Address Mobile/Tel No Second Reference Name And Address Permanent Address Address PIN Mobile/Tel No Emergency Contact Details Name and Address Mobile/Tel No Email Other Details Self Declaration FLAT NO. 159,PICKET CASTLE,PICKET,SEC-BAD SECUNDERABAD ANDHRA PRADESH HYDERABAD MARREDPALLY 500026 8985995743 SANTHOSHI PRIYA , FLAT NO. 159,PICKET CASTLE, PICKET, SECUNDERBAD- 500026 8985995743 SANTHOSHIPRIYA1243@GMAIL.COM 13-1003607369 FRESH NORMAL NORMAL SANTHOSHI PRIYA ARCOT ELLENDER 27/02/1991 HYDERABAD HYDERABAD ANDHRA PRADESH INDIA FEMALE SINGLE BIRTH STUDENT Y GRADUATE AND ABOVE Y MOLE ON LEFT ELBOW ELLENDER BABU ARCOT RAMA GOWRI KADIYALA 07/2011 FLAT NO. 159,PICKET CASTLE,PICKET,SEC-BAD SECUNDERABAD ANDHRA PRADESH HYDERABAD MARREDPALLY 500026 8985995743 SANTHOSHIPRIYA1243@GMAIL.COM ELLENDER BABU, FLAT NO. 159,PICKET CASTLE, PICKET SECUNDERABAD - 500026 9441704869 RAMA GOWRI, FLAT NO. 159,PICKET CASTLE,PICKET SECUNDERABAD 500026

I owe allegiance to the sovereignty, unity and 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 and I affirm that the information given by me in this form and the enclosures is true and I am solely responsible for its accuracy, and 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. Place SECUNDERABAD Date 07/04/2013