File Number (For Office Use Only)
GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS
PASSPORT APPLICATION FORM
Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of
the application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original
documents at the time of submission of the form.
Service Required
Application Reference Number 22-0020894878
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SAMARTH SAMPAT GHORPADE
Date of Birth (DD/MM/YYYY) 02/12/2001
Validity Required NA
Place of Birth (Village/Town/City) MUMBAI
District MUMBAI
State/UT MAHARASHTRA
Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status SINGLE cannot sign.
Citizenship of India by BIRTH
PAN DLUPG9691B
Voter Id NNX4690905
Employment Type STUDENT
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 941062456948
Family Details
Father's Name SAMPAT NARAYAN GHORPADE
Mother's Name RAMESHWARI SAMPAT GHORPADE
Present Residential Address Details
B/703, ROSEWOOD, PRESTIGE RESIDENCY, WAGHBIL,
Address GHODBUNDER ROAD THANE WEST, THANE CITY,
MAHARASHTRA
PIN 400615
Police Station CHITALSAR MANPADA
Mobile/Tel No. 8850206903
E-mail [email protected]
Permanent Residential Address
J/8, JAIHIND COLONY, NANEPADA ROAD,, MULUND EAST,
Address
MUMBAI, MAHARASHTRA, INDIA
PIN 400081
Police Station MULUND
Mobile/Tel No. 8850206903
Emergency Contact Details
Name and Address SAMPAT GHORPADE THANE WEST
Mobile/Tel No. 9920184411
Other Details
Payment Details
Mode of Payment UPI
Date 06/12/2022
Receipt/Reference No. CPACGUUBF2
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.PAN Card issued by the Income Tax Department
2.Aadhaar Card (Address Proof)
Self Declaration
I owe allegiance to the sovereignty, unity & 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. I have not contravened any of the conditions
relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing
any material information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my
application for an Indian passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. 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.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me
in the form is bonafide.
Place THANE Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 18/02/2023 to sign)
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