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 25-0005854822
Applying For REISSUE
VALIDITY EXPIRED WITHIN 3
If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name KSHITIJ RAJENDRAKUMAR GARACH
Date of Birth (DD/MM/YYYY) 13/08/1987
Validity Required NA
Place of Birth (Village/Town/City) VADODARA
District VADODARA
State/UT GUJARAT Signature/Left Hand Thumb
Impression of Illiterate Applicant and
Region/Country INDIA Minors who cannot sign.
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
Employment Type PRIVATE
Is either of your parent (in case of
minor)/spouse, a government N
servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR
Y
category?
Aadhaar Number 595348629580
Family Details
Father's Name RAJENDRAKUMAR BIHARILAL GARACH
Mother's Name URVASHIBEN RAJENDRAKUMAR GARACH
Present Residential Address Details
389 VAIKUNTH SOCIETY, WAGHODIYA ROAD VADODARA,
Address
VADODARA, GUJARAT
PIN 390019
Police Station BAPOD
Mobile/Tel No. 9173474613
E-mail [email protected]
Emergency Contact Details
Name and Address AKSHAY KHAMAR
Mobile/Tel No. 8511983583
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number N6236226
Date of Issue 13/01/2016
Date of Expiry 12/01/2026
Place of Issue AHMEDABAD
File Number AH3079534428416
Details of Previous/Current Diplomatic/Official Passport
Passport Number F8661445
Date of Issue 22/06/2006
Date of Expiry 21/06/2016
Place of Issue AHMEDABAD
Other Details
Payment Details
Mode of Payment UPI
Date 27/04/2025
Receipt/Reference No. CPAFBMYOK2
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
1.Permanent Account Number Card issued by the Income-tax Department having the date of birth of the applicant
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 AHMEDABAD Signature/Left Hand Thumb Impression
of Applicant (If applicant is minor, either
Date 24/04/2025 parent to sign)
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