Application form

Paste one passport size

photograph here (2 X 2)

Ref Id TECC674301
PERFORMA FOR VERIFICATION OF NATIONALITY STATUS/ANTECEDENTS
(PLEASE TYPE OR PRINT)

1. FULL NAME:
2. ALIASES, IF ANY:
3. (a) FULL NAME OF FATHER:
(b) FULL NAME OF MOTHER:
(c) FULL NAME OF SPOUSE:
4. DATE AND PLACE OF BIRTH:
5.
6.
7.
8.

9.

____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
(DD-MM-YYYY)
(VILLAGE)
(DISTRICT)
PRESENT OCCUPATION:
____________________________________________________
NATIONALITY:
____________________________________________________
PRESENT ADDRESS IN USA
____________________________________________________
____________________________________________________
COMPLETE PERMANENT ADDRESS IN INDIA:
_______________________________________
____________________________________________________
____________________________________________________
DETAILS OF PASSPORT:
PASSPORT NO:______________ DATE OF ISSUE: _____________
PLACE OF ISSUE: ____________ DATE OF EXPIRY: ____________

10.
11.
12.
13.
14.

VISBILE DISTINGUISHING MARKS IF ANY:_____________________________________________

DATE OF LEAVING INDIA:
____________________________________________________
Contract
PERIOD OF STAY ABROAD:
____________________________________________________
DATE OF LOSS OF PASSPORT: ____________________________________________________
NAME & ADDRESS OF TWO
(1) _________________________________________________
RELATIVES / FRIENDS (AT THE
________________________________________________________________________
PLACE OF PERMANENT RESIDENCE IN

(2) _____________________________________________________________________

___________________________________________________
15. NAME & ADDRESS OF TRAVEL ____________________________________________________
AGENT INVOLVED IN SENDING ____________________________________________________
THE INDIVIDUAL ABROAD
____________________________________________________
INDIA, Given In Sr.8 Above)

NOTE: Please Complete all entries Legibly and fully: Incomplete Information will only lead to delay in the process of issuing passport.

Regards
Ganesan