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 25-1000377793

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details

Applicant's Name SWAPAN MAHANTA

Date of Birth (DD/MM/YYYY) 25/08/2000

Validity Required NA

Place of Birth (Village/Town/City) GANGARAMPUR

Region/Country BANGLADESH

Gender MALE

Marital Status SINGLE

Signature/Left Hand Thumb Impression
Citizenship of India by BIRTH of Illiterate Applicant and Minors who
PAN IGVPM0643G cannot sign.

Voter Id UNZ1951631

Employment Type HOME MAKER

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification 7TH PASS OR LESS

Are you eligible for Non-ECR category? Y

Visible Distinguishing Mark ON

Aadhaar Number 236730602706

Family Details

Father's Name BHUPAN MAHANTA

Mother's Name SADHONA MAHANTA

Legal Guardian's Name BHUPAN MAHANTA

Present Residential Address Details

 JALGHAR TALMANDIRA, TALMANDIRA, SOUTH DINAJPUR,
Address
WEST BENGAL

PIN 733102

Police Station BALURGHAT

Mobile/Tel No. 8116588607 / 8116588607

E-mail SWAPANMAHANTA074@GMAIL.COM

Permanent Residential Address

JALGHAR TALMANDIRA, TALMANDIRA, SOUTH DINAJPUR,

Address
WEST BENGAL

PIN 733102

Police Station BALURGHAT

Mobile/Tel No. 8116588607 / 8116588607

Emergency Contact Details

Name and Address SWAPAN MAHANTA,TALMANDIRA

Mobile/Tel No. 8116588607 / 8116588607

E-mail SWAPANMAHANTA074@GMAIL.COM

Other Details
Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)

Fee amount in (Rs)

If paid by Demand Draft(DD), provide the following details

DD Issue Date (dd/mm/yyyy)

DD Expiry Date (dd/mm/yyyy)

Bank Name

Branch

Enclosures

1.A declaration given by the Head of the Orphanage/Child Care Home on their official letter head of the organization confirming the
DOB 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 TRUST Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 09/01/2025 to sign)

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