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The document is a passport application form for an individual named Surender Singh, applying for a fresh normal passport. It includes personal details such as date of birth, address, and family information, along with payment details for the application fee. The applicant affirms the accuracy of the information provided and acknowledges the legal implications of false information under the Passports Act, 1967.

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31 views2 pages

Untitled 2

The document is a passport application form for an individual named Surender Singh, applying for a fresh normal passport. It includes personal details such as date of birth, address, and family information, along with payment details for the application fee. The applicant affirms the accuracy of the information provided and acknowledges the legal implications of false information under the Passports Act, 1967.

Uploaded by

gul dalal
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 25-0001064266

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name SURENDER SINGH

Date of Birth (DD/MM/YYYY) 20/09/1970

Validity Required NA

Place of Birth (Village/Town/City) HISAR

District HISAR

State/UT HARYANA

Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.

Citizenship of India by BIRTH

Employment Type SELF EMPLOYED

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 896359033034

Family Details
Father's Name BIR SINGH DALAL

Spouse's Name SUSHILA


Present Residential Address Details
Address 2675 SECTOR 4, HISAR, HISAR, HARYANA

PIN 125001

Police Station CITY HISAR


Mobile/Tel No. 7082967327

E-mail SURENDER_CHOUDHARY@YAHOO.COM
Permanent Residential Address
Address 2675 SECTOR 4, HISAR, HISAR, HARYANA

PIN 125001

Police Station CITY HISAR

Mobile/Tel No. 7082967327


Emergency Contact Details
Name and Address SUSHILA

Mobile/Tel No. 9991667018


Other Details
Payment Details
Mode of Payment UPI

Date 18/01/2025

Receipt/Reference No. CPAESCGMM0

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


Enclosures
1.Election Photo Identity Card (EPIC) issued by the Election Commission of India

2.Electors Photo Identity Card (EPIC)


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 GURGAON Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 18/01/2025 to sign)

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