Government of India

Ministry of External Affairs

Passport Application Form (No.1)
(For New / Re-issue/ Replacement of Lost/Damaged Passport)
(Please tick the required category)

MDUI16266809

Paste your
unsigned recent
colour
photograph.
Size: 3.5 X 3.5 cm

Please read the Passport Information Booklet carefully before filling the form, in CAPITAL
LETTERS in blue/ black ball point pen only:
(CAUTION: Please furnish correct information. Furnishing of incorrect information would attract
penal provisions as prescribed under the Passports Act, 1967). Please produce your original
documents at the time of submission of the form.
For official use only
File Number .. Police Verification required

Fee Amount Rs.

Cash /D.D

1000

CASH

Bank Code

(Yes/No)

D.D No.

ECR / ECNR

Signature of Checking Official

Date of Issue of D.D

MDU027

Signature
or
Thumb Impression

1. Name of applicant as it should appear in the Passport (Initials not allowed)

Surname
(with documentary
proof)

JOE ANITOE VARUN

2. In case of change of name/surname (after marriage or otherwise with documentary proof), please indicate
the previous name/surname in full

NO
3. Sex

MALE

4. Date of Birth: 09-NOV-1990

(with documentary proof)
In words.________________________________________________
5. Place of Birth: Village / Town, District, State, Country (with Documentary Proof)

THOOTHUKUDI

THOOTHUKUDI TAMILNADU

6. Father/Legal Guardian's Full Name (including surname, if any): (Initials not allowed)

JOSEPH REX PITCHIAH

7. Mothers Full Name (including surname, if any): (Initials not allowed)

CLAUDIA REX
8. If married, Full Name of wife/husband (including surname, if any). (Initials not allowed).

8 (i) If divorced/widow/widower, Please indicate the category with documentary proof.

JOE ANITOE VARUN JOSEPH REX PITCHIAH

MDUI16266809

Given Name

11-SEP-2009

JOSEPH REX PITCHIAH

9. Current Residential Address (where staying presently), Residing since

01-JAN-2004
(In case of students, please see Section III of Passport Information Booklet)

O.NO:35,N.NO:17,MUTHUSAMY STREET,
THOOTHUKUDI-PO AND DT-628 001,
TAMILNADU.
Telephone No /Email Address.
-----

Mobile No.

0
0
9 (a) If you have been resident at your current address for less than one year, please furnish other addresses
of your residence during the last one year.
01-DEC-2009
01-JUL-2008
01-DEC-2009
01-JUL-2008
From..To.
FromTo..
HINDUSTAN INSTITUTE OF ENG AND TECH

HINDUSTAN INSTITUTE OF ENG AND TECH

BATCH NO:108, 40, G.S.T. ROAD,

BATCH NO:108, 40, G.S.T. ROAD,

ST.THOMAS MOUNT,CHENNAI-600 016.

ST.THOMAS MOUNT,CHENNAI-600 016.

10. Permanent Address with PIN code (if the permanent address is same as the present address write Same
only)

THOOTHUKUDI-PO AND DT-628 001,

TAMILNADU.
11. Details of latest held/existing Ordinary / Diplomatic / Official passport(s):
(i)
(ii)
(iii)
(iv)

Passport Office File No./Passport(s) No................

Date and Place of Issue: ............................../Date of Expiry ...
In case passport was applied for and not issued, please give File No. & Date
Has your passport(s) ever been lost / damaged (if so attach FIR and give details)..
..

11. (a) If you have returned to India on Emergency Certificate (EC) or were ever deported or repatriated,
please furnish details:
EC No., date and place of issue & attach seizure memo in original ...
Place & Country from where deported / repatriated and reason thereof:
....
.
12. Other Details:
A.M.E
a) Educational Qualifications..

A MOLE IN THE LEFT LEG

b) Visible Distinguishing Mark, if any.
STUDENT
170
c) Height cms.
d) Profession ......................................................
13. Are you working in Central Government/ State Govt/ PSU/ Statutory Bodies (Y)es/ (N)o
If Yes attach Identity Certificate (As per Annexure B of Passport Information booklet).
14. Are you a citizen of India by: (B)irth/(D)escent/(R)egistration/(N)aturalisation; .
If you have ever possessed any other citizenship, please indicate previous citizenship
15. Emigration Check Not Required status? Yes/No
(Please note that all 10 and above qualified applicants are eligible for ECNR status.)
If yes, mention the eligible category (see Section III of Passport Information Booklet) and enclose copy
of relevant certificate/document__________________________________________________________

MDUI16266809

O.NO:35,N.NO:17,MUTHUSAMY STREET,

Mother

Passport/ File No.

_______________

Date & Place of Issue/ Application

_________________________________

Father

_______________

_________________________________

17. (a) Have you at any time during the period of Five years immediately preceding the date of this
application been convicted by a court in India for any criminal offence & sentenced to imprisonment
for two years or more? If so, give name of the court, case number and relevant sections of Law.
(Attach copy of judgement)
..

MDUI16266809

16. In case of minors (applicant below the age of 18), if EITHER of the parents hold a Valid Indian
Passport or has applied for it give the following details. Please see and fill up attached Annexure-H.

(b) Are any criminal proceedings pending against you before a court in India? If so, give name of court,
case number and relevant sections of Law.
..
(c) If answer at (b) is (Y)es, please furnish No Objection Certificate from competent court for grant of
Passport.

....
(d) Have you been ever refused/denied passport? If yes, give details:
...
...

18. Particulars of person to be intimated in the event of death or accident:

Name
..
Address
..
..
Mobile / Tel. No. / email ID
19. Self Declaration:
I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily
acquired citizenship or travel documents of any other country. I have not lost, surrendered or been deprived
of citizenship of India. The information given by me in this form and enclosures is true and I am solely
responsible for its accuracy. I am aware that it is an offence under the Passports Act, 1967 to furnish any
false information or to suppress any material information with a view to obtaining a passport or any other
travel document.
I further declare that I have no other passport/ travel document.

Date .
Place

(Signature/Thumb Impression of Applicant)

(Left Hand Thumb Impression if male and Right
Hand Thumb Impression if female)

JOE ANITOE VARUN

(f) Have you ever applied/granted political asylum by any foreign country? If yes, give details.
..
..

JOSEPH REX PITCHIAH

(e) Has your passport ever been impounded / revoked? If yes, give details:
..
..

20. Enclosures:
1 Proof of date of birth . 2 Proof of Residence
3 Educational Qualifications 4 ......

Signature/date

Granted by Name

Signature/date

Scanned by Name

Signature/date

Dispatched by Name

Signature/date

JOSEPH REX PITCHIAH

Checked by Name

JOE ANITOE VARUN

(For Official Use Only)

MDUI16266809

5 6 .

PERSONAL PARTICULARS FORM

(In Duplicate)

Paste your
cross signed
recent colour
photograph.
Size: 3.5 X 3.5 cm

1. Full name (Initials not allowed)

JOSEPH REX PITCHIAH

JOE ANITOE VARUN

MALE
2. Sex: Male / Female / Others .
(a) Has the applicant ever changed name?
(b) If yes, previous name: NO
.
THOOTHUKUDI
09-NOV-1990
4. Date of Birth:
5. Place of Birth
STUDENT
6. Profession .
JOSEPH REX PITCHIAH
7. a) Father
(Surname)
(Name)
CLAUDIA
REX
b) Mother.
(Surname)
(Name)
c) Husband / wife . .
(Surname)
(Name)

a) Permanent Address & Tel. No.

8(b) Present Residential Address & Tel. No, along with
along with Police Station
Police Station and residing since
O.NO:35,N.NO:17,MUTHUSAMY STREET,
O.NO:35,N.NO:17,MUTHUSAMY STREET,
.

THOOTHUKUDI-PO AND DT-628 001,

THOOTHUKUDI-PO AND DT-628 001,
.

TAMILNADU.
TAMILNADU.
.

0
.

10. References: Names and Addresses of two responsible persons in the applicants locality who can vouch
for the applicant.
(1) Name, Address & Tel. No.
(2) Name, Address & Tel. No.
.

11. Citizenship of India by:

Birth

Descent

Registration

Naturalization

12. Furnish details of previous passport / travel document, if any:

(i) Passport/Travel document No: ... (ii) Date & Place of issue .
For Police Use Only
Recommended Passport: YES/NO

Signature or Thumb Impression of the applicant

(Left Hand T.I. if male and Right Hand T.I. if female)

MDUI16266809

9. If you have not been resident at the address given at COLUMN 8(b) continuously for the last one year,
please furnish other address(es) with duration(s) resided (Please furnish an additional set of P P Forms
for each address with Police station.
01-JUL-2008
01-DEC-2009
01-DEC-2009
01-JUL-2008
From..To.
FromTo.
HINDUSTAN
INSTITUTE
OF
ENG
AND TECH
HINDUSTAN INSTITUTE OF ENG AND TECH
________________________________
_________________________________
BATCH NO:108, 40, G.S.T. ROAD,
BATCH
NO:108, 40, G.S.T. ROAD,
________________________________
_________________________________
ST.THOMAS MOUNT,CHENNAI-600 016.
ST.THOMAS MOUNT,CHENNAI-600 016.
________________________________
_________________________________
________________________________
_________________________________

PERSONAL PARTICULARS FORM

(In Duplicate)

Paste your
cross signed
recent colour
photograph.
Size: 3.5 X 3.5 cm

1. Full name (Initials not allowed)

JOSEPH REX PITCHIAH

JOE ANITOE VARUN

MALE
2. Sex: Male / Female / Others .
(a) Has the applicant ever changed name?
(c) If yes, previous name: NO
..
THOOTHUKUDI
09-NOV-1990
4. Date of Birth: 5. Place of Birth
STUDENT
6. Profession ..
JOSEPH REX PITCHIAH
7. a) Father ..
(Surname)
(Name)
CLAUDIA REX
b) Mother..
(Surname)
(Name)
c) Husband / wife . .
(Surname)
(Name)

a) Permanent Address & Tel. No.

8(b) Present Residential Address & Tel. No, along with
along with Police Station
Police Station and residing since
O.NO:35,N.NO:17,MUTHUSAMY STREET,
O.NO:35,N.NO:17,MUTHUSAMY
STREET,
.

THOOTHUKUDI-PO
AND
DT-628
001,
THOOTHUKUDI-PO AND DT-628 001,
.

TAMILNADU.
TAMILNADU.
.

0
.

9. If you have not been resident at the address given at COLUMN 8(b) continuously for the last one year,
please furnish other address(es) with duration(s) resided (Please furnish an additional set of P P Forms
for each address with Police station.
01-JUL-2008
01-DEC-2009
01-DEC-2009
01-JUL-2008
From..To.
FromTo.
HINDUSTAN INSTITUTE OF ENG AND TECH
HINDUSTAN
INSTITUTE OF ENG AND TECH
________________________________
_________________________________
BATCH
NO:108, 40, G.S.T. ROAD,
________________________________
_________________________________
BATCH NO:108, 40, G.S.T. ROAD,
________________________________
_________________________________
ST.THOMAS
MOUNT,CHENNAI-600 016.
ST.THOMAS MOUNT,CHENNAI-600 016.
________________________________
_________________________________

11. Citizenship of India by:

Birth

Descent

Registration

Naturalization

12. Furnish details of previous passport / travel document, if any:

(i) Passport/Travel document No: ... (ii) Date & Place of issue .
For Police Use Only
Recommended Passport: YES/NO

Signature or Thumb Impression of the applicant

(Left Hand T.I. if male and Right Hand T.I. if female)

MDUI16266809

10. References: Names and Addresses of two responsible persons in the applicants locality who can vouch
for the applicant.
(1) Name, Address & Tel. No.
(2) Name, Address & Tel. No.
.