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This document is a passport application form for Kshitij Rajendrakumar Garach, applying for a reissue of his passport due to expiration. The application includes personal details, previous passport information, and a declaration of the authenticity of the information provided. Payment for the application has been made via UPI, and necessary enclosures are listed.

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Khamar Akshay
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13 views3 pages

View - Print Submitted Form

This document is a passport application form for Kshitij Rajendrakumar Garach, applying for a reissue of his passport due to expiration. The application includes personal details, previous passport information, and a declaration of the authenticity of the information provided. Payment for the application has been made via UPI, and necessary enclosures are listed.

Uploaded by

Khamar Akshay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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 25-0005854822

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 KSHITIJ RAJENDRAKUMAR GARACH

Date of Birth (DD/MM/YYYY) 13/08/1987

Validity Required NA

Place of Birth (Village/Town/City) VADODARA

District VADODARA

State/UT GUJARAT Signature/Left Hand Thumb


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

Marital Status SINGLE

Citizenship of India by BIRTH

Employment Type PRIVATE

Is either of your parent (in case of


minor)/spouse, a government N
servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR


Y
category?

Aadhaar Number 595348629580

Family Details
Father's Name RAJENDRAKUMAR BIHARILAL GARACH

Mother's Name URVASHIBEN RAJENDRAKUMAR GARACH


Present Residential Address Details
389 VAIKUNTH SOCIETY, WAGHODIYA ROAD VADODARA,
Address
VADODARA, GUJARAT
PIN 390019

Police Station BAPOD

Mobile/Tel No. 9173474613

E-mail GKSHITIJ@YAHOO.COM
Emergency Contact Details
Name and Address AKSHAY KHAMAR

Mobile/Tel No. 8511983583


Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number N6236226

Date of Issue 13/01/2016

Date of Expiry 12/01/2026

Place of Issue AHMEDABAD

File Number AH3079534428416


Details of Previous/Current Diplomatic/Official Passport
Passport Number F8661445

Date of Issue 22/06/2006

Date of Expiry 21/06/2016

Place of Issue AHMEDABAD


Other Details
Payment Details
Mode of Payment UPI

Date 27/04/2025

Receipt/Reference No. CPAFBMYOK2

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)


Enclosures
1.Permanent Account Number Card issued by the Income-tax Department having the date of birth of the applicant

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 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 AHMEDABAD Signature/Left Hand Thumb Impression


of Applicant (If applicant is minor, either
Date 24/04/2025 parent to sign)
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