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 22-0015343622
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name AMBUJ KUMAR
Date of Birth (DD/MM/YYYY) 25/05/1998
Validity Required NA
Place of Birth (Village/Town/City) BALLABGARH
District FARIDABAD
State/UT HARYANA
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
Employment Type STUDENT
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? Y
Aadhaar Number 639927234198
Family Details
Father's Name BASHISHIT SHARMA
Mother's Name RANJU DEVI
Legal Guardian's Name RANJU DEVI
Present Residential Address Details
Address 586,SAMAYPUR ROAD, RAJEEV COLONY, BALLABGARH,
FARIDABAD, HARYANA
PIN 121004
Police Station SECTOR 58
Mobile/Tel No. 9582599596
E-mail [email protected]
Permanent Residential Address
586,SAMAYPUR ROAD, RAJEEV COLONY, BALLABGARH,
Address
FARIDABAD, HARYANA
PIN 121004
Police Station SECTOR 58
Mobile/Tel No. 9582599596
Emergency Contact Details
Name and Address RAHUL
Mobile/Tel No. 8743048130
E-mail [email protected]
Other Details
Payment Details
Mode of Payment UPI
Date 16/09/2022
Receipt/Reference No. CPACAVPHJ1
Amount Received (Rs.) 2000.00 (TWO THOUSAND ONLY)
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Driving Licenses (valid and within the jurisdiction of state of submission of application)
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 BALLABGARH Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 11/09/2022 to sign)
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