HIGH COMMISSION OF INDIA,WISMA HRIH LOTUS,LEVEL 1,442,JALAN

PAHANG,SETAPAK,53000,KUALA LUMPUR,MALAYSIA
00-603-62052350 http://www.indianhighcommission.com.my/
EMERGENCY CERTIFICATE PREVIEW

  भारत गणराज्य   REPUBLIC OF INDIA

Paste your unsigned recent color photograph of Size 2"X2" and Signature/Left Hand Thumb Impression in the box provided

टाइप/Type राष्ट्र कोड/CountryCode आपाती प्रमाणपत्र नं./EC

No.

P IND  
Paste your unsigned
उपनाम/Surname
recent color DAS 
photograph Size 2"X2" दिया गया नाम/Given Name(s)
and Signature/Left AYAN
Hand Thumb राष्ट्रीयता/Nationality लिंग/Sex जन्मतिथि/Date of Birth
Impression in the box INDIAN M 31/10/1995

provided below जन्म स्थान/Place of Birth

Generated on: Monday, May 1, 2023 5:27:45 PM

PANIHATI, WEST BENGAL 
जारी करने का स्थान/Place of Issue
 
जारी करने की तिथि/Date of Issue समाप्ति की तिथि/Date of Expiry
   

पिता/कानूनी अभिभावक का नाम/Name of Father/Legal Guardian

MOHAN DAS    
माता का नाम/Name of Mother

NANDA RANI DAS     

पति या पत्नी का नाम/Name of Spouse
वर्तमान पता /Present Address

11,JALAN SR 3/1,SERDANG RAYA  

SERI KEMBANGAN,43300,SELANGOR  
स्थायी पता /Permanent Address

PURNACHANDRA DAS ROAD  

PANIHATI, NORTH 24 PARGANAS  
PIN:700113, WEST BENGAL, INDIA    
पुराना पासपोर्ट नं./जारी करने की तिथि / पी आई ए /Old Passport No./Date of Issue/PIA फ़ाइल नं./File No.

P6757187  02/01/2017  KOLKATA  

Applicant Details
Application Reference Number 23-2001786538
Applicant's Name AYAN  DAS
Applicant's Alias Name N
Applicant's Change In Name N
Date of Birth (DD/MM/YYYY) 31/10/1995
Place of Birth (Village/Town/City) PANIHATI
District NORTH 24 PARGANAS
State/UT WEST BENGAL
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN CLMPD9595E
Employment Type OTHERS
Educational Qualification 10TH PASS AND ABOVE
Visible Distinguishing Mark NO
Aadhaar Number 470136929482
Family Details(as in passport)
Father's Name MOHAN DAS
Mother's Name NANDA RANI DAS
Address in India
To be printed on EC PURNACHANDRA DAS ROAD,PANIHATI, NORTH 24
PARGANAS,PIN:700113, WEST BENGAL, INDIA
Mobile/Telephone Number 0918697025115
Present Address
To be printed on EC 11,JALAN SR 3/1,SERDANG RAYA,SERI
KEMBANGAN,43300,SELANGOR
Country MALAYSIA
Mobile/Telephone Number 0169337187
Emergency Contact Details
Name and Address GILL
Mobile/Telephone Number 0183816528
E-mail
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport/ Identity Y
Certificate
Passport Number P6757187
Date of Issue 02/01/2017
Date of Expiry 01/01/2027
Place of Issue KOLKATA
File Number CA2069823366916
Previous Passport Status LOST PASSPORT
Have you ever applied for passport, but not issued? N
Details of Previous/Current Diplomatic/Official Passport/Identity N
Certificate
Other Details
1) Provide the following details if there are any criminal proceedings pending against the applicant.
1.1) Are any proceedings in respect of an offence alleged to have been committed by you pending before a criminal court in India? N
1.2) Has any warrant or summons for your appearance been issued and pending before a court under any law for the time being in force? N
1.3) Has a warrant for your arrest been issued by a court under any law for the time being in force? N
1.4) Has an order prohibiting your departure from India been made by any court? N
2) Provide the following details if the applicant has been convicted by a court in India.
2.1) 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
offence involving moral turpitude and sentenced in respect thereof to imprisonment for not less than two years? N
3) Provide the following details if the applicant has been refused/denied passport.
3.1) Have you ever been refused/denied passport? N
3.2) Has your passport ever been impounded or revoked? N
3.3) Has your passport ever been revoked? N
4) Provide the following details if applicant has applied for or been granted foreign citizenship.
4.1) Have you ever applied for or been granted citizenship by any other country? N
4.2) Have you ever held the passport of any other country at any time? N
4.3) Have you ever surrendered your Indian passport? N
4.4) Have you ever applied for renunciation of Indian citizenship? N
5) Provide the following details if applicant has returned to India on Emergency Certificate.
5.1) Have you ever returned to India on Emergency Certificate (EC)? N
5.2) Have you ever been deported from any country? N
5.3) Have you ever been repatriated from any country back to India? N
Self Declaration
I declare:
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.
I understand:
That Ministry of External Affairs (MEA) (or its implementation partner agencies/stakeholders/third parties) may undertake required checks to confirm the accuracy
and authenticity of evidence I have provided and documents I have submitted with this application.
That the information I provide, including biometric data (if any), will be treated in confidence, but it may be disclosed to other government departments, agencies,
local authorities, foreign governments, and other implementation partner agencies/stakeholders/third parties to enable MEA or those bodies to perform their duties.
 That providing biometric information, if collected as part of an application, is confirmation of my consent to getting the biometric information checked to verify
identity.
That the Passport and related services applications may be handled by the Indian Embassies/Consulates/ Passport Office/other offices including outside of the
country in which I have applied and that this may involve the transfer of my application and supporting documents to and from the respective offices.
That my details may, in certain circumstances, be passed to Police, Intelligence and other Fraud Detection & Prevention agencies. I also understand that such
agencies may provide related information about me to MEA.

Undertaking:
"I am aware that on submission of my EC application all my previous Indian Passport including the most recent one will be cancelled. I am also aware that EC is
one time travel document for my travel from abroad to India and after obtaining EC I must travel on it to India. After submission of EC application further Passport I
am required to obtain from India only."

Place KUALA
LUMPUR Signature/Left Hand Thumb Impression of Applicant

(If applicant is minor, either parent to sign)

Date 01/05/2023