5/29/24, 12:53 PM Application Form
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 24-0009413932
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name RABIYA KHATOON
Date of Birth (DD/MM/YYYY) 01/01/2006
Validity Required NA
Place of Birth (Village/Town/City) PATHARDIH
District DHANBAD
Region/Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN OWQPK7685M
Employment Type HOME MAKER
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark MOLE ON MIDDLE FINGER OF RIGHT HAND
Aadhaar Number 341104764209
Family Details
Father's Name HUSSAIN SAIKH
Mother's Name SALIMA KHATOON
Spouse's Name MD SHAHZAD ALAM
Present Residential Address Details
SHAMSHER NAGAR,BYE PASS ROAD,BEHIND TAJ PALACE, DHANBAD,
Address
DHANBAD, JHARKHAND
PIN 828130
Police Station BHULI
Mobile/Tel No. 7979960176 / 7061546601
E-mail [email protected]
Emergency Contact Details
Name and Address MD SHAHZAD ALAM
Mobile/Tel No. 7061546601
Other Details
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 DHANBAD
Date 29/05/2024
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/1
