4/7/24, 9:02 PM View/Print Submitted Form
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 24-1004159443
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name NISHITH SINGH
Date of Birth (DD/MM/YYYY) 23/05/1987
Validity Required NA
Place of Birth (Village/Town/City) LUCKNOW
District LUCKNOW
State/UT UTTAR PRADESH
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 DSSPS6228D
Employment Type PRIVATE
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? N
Visible Distinguishing Mark CUT ON THE LEFT EYEBROW
Family Details
Father's Name SATYA PRAKASH SINGH
Mother's Name BINDU SINGH
Present Residential Address Details
F1, 146/1 4TH CROSS PANDURANGANAGAR, BENGALURU,
Address
BENGALURU, KARNATAKA
PIN 560076
Police Station PUTTENAHALLI
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Mobile/Tel No. 9999879306
E-mail [email protected]
Permanent Residential Address
4/154 VIRAT KHAND GOMTI NAGAR, LUCKNOW, LUCKNOW,
Address
UTTAR PRADESH, INDIA
PIN 226010
Police Station GOMTI NAGAR
Mobile/Tel No. 9450644307
Emergency Contact Details
Name and Address SATYA PRAKASH SINGH
Mobile/Tel No. 9450644307
Other Details
Payment Details
Mode of Payment UPI
Date 29/03/2024
Receipt/Reference No. CPADRFJCP5
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.PAN Card issued by the Income Tax Department
2.Rent Agreement
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 BENGALURU Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 29/03/2024 to sign)
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