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 25-1000377793
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SWAPAN MAHANTA
Date of Birth (DD/MM/YYYY) 25/08/2000
Validity Required NA
Place of Birth (Village/Town/City) GANGARAMPUR
Region/Country BANGLADESH
Gender MALE
Marital Status SINGLE
Signature/Left Hand Thumb Impression
Citizenship of India by BIRTH of Illiterate Applicant and Minors who
PAN IGVPM0643G cannot sign.
Voter Id UNZ1951631
Employment Type HOME MAKER
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 7TH PASS OR LESS
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark ON
Aadhaar Number 236730602706
Family Details
Father's Name BHUPAN MAHANTA
Mother's Name SADHONA MAHANTA
Legal Guardian's Name BHUPAN MAHANTA
Present Residential Address Details
JALGHAR TALMANDIRA, TALMANDIRA, SOUTH DINAJPUR,
Address
WEST BENGAL
PIN 733102
Police Station BALURGHAT
Mobile/Tel No. 8116588607 / 8116588607
E-mail [email protected]
Permanent Residential Address
JALGHAR TALMANDIRA, TALMANDIRA, SOUTH DINAJPUR,
Address
WEST BENGAL
PIN 733102
Police Station BALURGHAT
Mobile/Tel No. 8116588607 / 8116588607
Emergency Contact Details
Name and Address SWAPAN MAHANTA,TALMANDIRA
Mobile/Tel No. 8116588607 / 8116588607
E-mail [email protected]
Other Details
Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)
Fee amount in (Rs)
If paid by Demand Draft(DD), provide the following details
DD Issue Date (dd/mm/yyyy)
DD Expiry Date (dd/mm/yyyy)
Bank Name
Branch
Enclosures
1.A declaration given by the Head of the Orphanage/Child Care Home on their official letter head of the organization confirming the
DOB 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 TRUST Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 09/01/2025 to sign)
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