11/5/2017 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 17­1010642769
Applying For REISSUE
If Re­issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name YASH VARDHAN DEORA
Date of Birth (DD/MM/YYYY) 22/06/1992
Validity Required NA
Place of Birth (Village/Town/City) KOLKATA
District KOLKATA
State/UT WEST BENGAL
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN AXSPD5493P
Employment Type SELF EMPLOYED
Is either of your parent (in case of minor)/spouse,
N
a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non­ECR category? Y
Aadhaar Number 805854090070
Family Details
Father's Name ASHOK KUMAR DEORA
Mother's Name RANJANA DEORA
Present Residential Address Details
Residing Since(MM/YYYY) 06/1992
P­37, MANIKTALLA MAIN ROAD,SCHEME ­7M, 1ST FLOOR, KOLKATA,
Address
PHOOLBAGAN, KOLKATA, WEST BENGAL
PIN 700054
Mobile/Tel No. 9830199392
E­mail Y.V.DEORA@GMAIL.COM
First Reference Name And Address ARPIT DOKANIA 194D MANIKTALLA MAIN ROAD, KOLKATA 700054
Mobile/Tel No. 9830800529
Second Reference Name And Address ABHISHEK GUPTA 3B, 273, MANIKTALLA MAIN ROAD, KOLKATA 700054
Mobile/Tel No. 9007049820
Permanent Residential Address
P­37, MANIKTALLA MAIN ROAD,SCHEME ­7M, 1ST FLOOR, KOLKATA,
Address
PHOOLBAGAN, KOLKATA, WEST BENGAL
PIN 700054
Mobile/Tel No. 9830199392
Emergency Contact Details
Name and Address ASHOK KUMAR DEORA
Mobile/Tel No. 9331080450
E­mail DEORAASHOK@GMAIL.COM
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number G7201880
Date of Issue 03/04/2008
Date of Expiry 02/04/2018
Place of Issue KOLKATA
File Number CALF00189008
Details of Previous/Current Diplomatic/Official Passport
Passport Number B2846505
Date of Issue 18/12/2000
Date of Expiry 17/12/2005
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/2
11/5/2017 Application Form
Place of Issue KOLKATA
Other Details
Self Declaration
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 KOLKATA
Date 05/11/2017

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 2/2