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 25-1001872041
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name ISHAQ MD
Date of Birth (DD/MM/YYYY) 08/07/1992
Validity Required NA
Place of Birth (Village/Town/City) MACHILIPATNAM
District KRISHNA
State/UT ANDHRA 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 BRBPM0293E
Employment Type SELF EMPLOYED
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark MOLE IN LEFT EYE
Aadhaar Number 815898780249
Family Details
Father's Name SHARIF BAASHA MD
Mother's Name NASEEMA BEGUM
Present Residential Address Details
32-6-41, NATTAYAPALEM, VISAKHAPATNAM, ANDHRA
Address
PRADESH
PIN 530012
Police Station GAJUWAKA
Mobile/Tel No. 9032998099
E-mail [email protected]
Permanent Residential Address
32-6-41, NATTAYAPALEM, VISAKHAPATNAM, ANDHRA
Address
PRADESH
PIN 530012
Police Station GAJUWAKA
Mobile/Tel No. 9032998099
Emergency Contact Details
Name and Address ABDUL QURDDUS
Mobile/Tel No. 9490991909
Other Details
Payment Details
Mode of Payment UPI
Date 12/02/2025
Receipt/Reference No. CPAEUMQDZ6
Amount Received (Rs.) 2000.00 (TWO THOUSAND ONLY)
Enclosures
1.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognized educational board
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 VISAKHAPATNAM Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 12/02/2025 to sign)
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