portal1.passportindia.gov.in apponlineproject secure viewdraftaction arn=13-0007206836
DESCRIPTION
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File Number (For Office Use Only)
Service Required
Application Reference Number 13-0007206836
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Validity Required
Applicant Details
Applicant's Name AXAYKUMAR JAGDISHBHAI PATEL
Date of Birth (DD/MM/YYYY) 11/02/1992
Place of Birth (Village/Town/City) KHERVA
District MEHSANA
State/UT GUJARAT
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN BQUPP6302F
Voter ID YJT1591593
Employment Type STUDENT
Is either of your parent (in case ofminor)/ spouse, a government servant?
N
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 988323153163
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 usingblue/black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of theapplication and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your originaldocuments at the time of submission of the form.
Signature/Left Hand ThumbImpression of Illiterate Applicant
and Minors who cannot sign.
Family Details
Father's Name JAGDISHBHAI JOITARAM PATEL
Mother's Name CHANDRIKABEN JAGDISHBHAI PATEL
Present Address Details
Residing Since(MM/YYYY) 05/2007
AddressAMBICANAGAR SOCIETY B/H GOVERNMENTHOSPITALKHERVA GUJARAT MEHSANA KHERVA
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftA...
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PIN 382711
Mobile/Tel No 9737590145
Email [email protected]
First Reference Name And AddressGOSWAMI AMITGIRI RAMESHGIRI, 1,AMBIKANAGARSOCIETY, KHERVA
Mobile/Tel No 8866556606
Second Reference Name And Address PATEL FALGUNKUMAR JAYESHBHAI, PARAVAS, KHERVA
Mobile/Tel No 9033574336
Permanent Address
AddressAMBICANAGAR SOCIETY B/H GOVERNMENTHOSPITALKHERVA GUJARAT MEHSANA KHERVA
PIN 382711
Mobile/Tel No 9737590145
Emergency Contact Details
Name and AddressKEYUR PATEL AMBICANAGAR SOCIETY B/H GOVERNMENTHOSPITAL,KHERVA
Mobile/Tel No 9725845235
Email [email protected]
Other DetailsFee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra)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
Enclosures1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
Self Declaration
I owe allegiance to the sovereignty, unity and integrity of India, and have not voluntarily acquired citizenship or travel document ofany other country. I have not lost, surrendered or been deprived of the citizenship of India and I affirm that the information given byme in this form and the enclosures is true and I am solely responsible for its accuracy, and I am liable to be penalized or prosecutedif found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false information or tosuppress any material information with a view to obtaining passport or travel document.
Place KHERVA
Date 11/06/2013
Signature/Left Hand Thumb Impression ofApplicant (If applicant is minor, either parent tosign)
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