3/7/2019 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 19-0003328638
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name IBRAT JAHAN
Date of Birth (DD/MM/YYYY) 01/03/1981
Validity Required NA
Place of Birth (Village/Town/City) CHITAKHAL
District SIWAN
State/UT BIHAR
Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN BFKPJ3626P
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
Visible Distinguishing Mark CUT MARK AT RIGHT SIDE OF EYE
Aadhaar Number 295458631740
Family Details
Father's Name SHAH MAHAMMAD ANSARI
Mother's Name BISHMILLAH KHATUN
Spouse's Name ANWAR RZA
Present Residential Address Details
D-2,JINDAL GARH COLONY, PATRAPALI, KOTRA ROAD, RAIGARH,
Address
CHHATTISGARH
PIN 496001
Mobile/Tel No. 9752695601
E-mail ANWARRZA@YAHOO.COM
Permanent Residential Address
C/O SURENDRA KIRANA STORES, SANGRAM CHOWK ,CAMP-1,BHILAI,
Address
CHHAWANI, DURG, CHHATTISGARH, INDIA
PIN 490001
Mobile/Tel No. 9752695601
Emergency Contact Details
Name and Address ANWAR RZA
Mobile/Tel No. 9109115944
E-mail ANWAR.RAZA@JSPL.COM
Details of Previous/Current Diplomatic/Official Passport

Passport Number F0733367

Date of Issue 05/11/2004
Date of Expiry 04/11/2014
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3/7/2019 Application Form
Place of Issue BHOPAL
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Bank/ Kisan/ Post Office Passbooks
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 RAIGARH
Date 07/03/2019

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