2/26/25, 10:40 PM View/Print Submitted Form

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 24-0010939288

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name VAISHNAV UPADHYAY

Date of Birth (DD/MM/YYYY) 19/10/2008

Validity Required Upto Age 18

Place of Birth (Village/Town/City) CITY

District SOUTH DELHI

State/UT DELHI Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender MALE

Marital Status SINGLE

Citizenship of India by BIRTH

Employment Type STUDENT

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 663506620352

Family Details
Father's Name NAPENDRA UPADHYAY

Mother's Name NEESHU UPADHYAY

Present Residential Address Details
34-B POCKET A-10 KALKAJI EXTENSION DELHI 110019,
Address
CITY, SOUTH EAST DELHI, DELHI

PIN 110019

Police Station GOVIND PURI

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Mobile/Tel No. 7042803775

E-mail LAKSHAY.UPA142006@GMAIL.COM
Permanent Residential Address
34-B POCKET A-10 KALKAJI EXTENSION DELHI 110019,
Address
CITY, SOUTH EAST DELHI, DELHI

PIN 110019

Police Station GOVIND PURI

Mobile/Tel No. 7042803775

Emergency Contact Details
VAISHNAV UPADHYAY POCKET A10 34 B KOHINOOR
Name and Address
APARTMENT KALKAJI EXTENSION

Mobile/Tel No. 7042803775

E-mail KUSHUPADHYAYA123@GMAIL.COM
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number P9217729

Date of Issue 01/06/2017

Date of Expiry 31/05/2022

Place of Issue CITY

Details of Previous/Current Diplomatic/Official Passport
Passport Number P9217729

Date of Issue 01/06/2017

Date of Expiry 31/05/2022

Place of Issue CITY

Other Details
Payment Details
Mode of Payment Debit/Credit Card

Date 22/06/2024

Receipt/Reference No. CPADXGJNR8

Amount Received (Rs.) 1000.00 (ONE THOUSAND ONLY)

Enclosures
1.Birth certificate issued by the Registrar of Births and Deaths or the Municipal Corporation or any other prescribed authority
whosoever has been empowered under the Registration of Birth and Deaths Act, 1969 to register the birth of a child born in India

2.Aadhaar Card (Address Proof)

Self Declaration

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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 NEW DELHI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 22/06/2024 to sign)

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