10/2/24, 1:02 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-1011463595
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name VARSHA TN
Date of Birth (DD/MM/YYYY) 07/12/1995
Validity Required NA
Place of Birth (Village/Town/City) ANAVATTI
District SHIVAMOGGA
State/UT KARNATAKA
Region/Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN BOLPV1393H
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark A BLACK MOLE BELOW THE NOSE
Aadhaar Number 895738829984
Family Details
Father's Name TENGINASASIMUTT MAHESHWARAIAH NEELAKANTA
Mother's Name LEELAVATHI
Spouse's Name SUHAS MJ
Present Residential Address Details
16 YAMMEDODDI ROAD, SUBHASHNAGARA, WARD NO 19, KADURU,
Address
CHIKKAMAGALURU, KARNATAKA
PIN 577548
Police Station KADUR
Mobile/Tel No. 9482624763
E-mail VARSHATN636@GMAIL.COM
Permanent Residential Address
16 YAMMEDODDI ROAD, SUBHASHNAGARA, WARD NO 19, KADURU,
Address
CHIKKAMAGALURU, KARNATAKA
PIN 577548
Police Station KADUR
Mobile/Tel No. 9482624763
Emergency Contact Details
SUHAS MJ, 16 YAMMEDODDI ROAD, SUBHASHNAGARA, WARD NO 19,
Name and Address
KADURU
Mobile/Tel No. 9980991356
E-mail SUHASMJ95@GMAIL.COM
Other Details
Enclosures
1.PAN Card issued by the Income Tax Department
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

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10/2/24, 1:02 PM Application Form
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 KADURU
Date 02/10/2024

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