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    neelesh shrivastava

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    View - Print Submitted Form

    Uploaded by

    neelesh shrivastava
    10 views3 pages

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    View_Print Submitted Form

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    Copyright:

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    10 views3 pages

    View - Print Submitted Form

    Uploaded by

    neelesh shrivastava

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    11/11/24, 11:23 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 24-0018019222

    Applying For FRESH

    Type of Application NORMAL

    Type of Passport Booklet NORMAL


    Applicant Details
    Applicant's Name VAISHALI SHRIVASTAVA

    Date of Birth (DD/MM/YYYY) 06/07/1995

    Validity Required NA

    Place of Birth (Village/Town/City) GWALIOR

    District GWALIOR

    State/UT MADHYA PRADESH

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

    Citizenship of India by BIRTH

    PAN LSSPS5969K

    Employment Type GOVERNMENT

    Organisation name GOVERNMENT

    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

    Visible Distinguishing Mark WHITE MOLE ON UPPER LIP

    Aadhaar Number 930701868713

    Family Details
    Father's Name SUNIL KUMAR SHRIVASTAVA

    Mother's Name BHAVANA SHRIVASTAVA

    https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-0018019222 1/3
    11/11/24, 11:23 PM View/Print Submitted Form

    Spouse's Name NEELESH SHRIVASTAVA


    Present Residential Address Details
    C/O NEELESH SHRIVASTAVA 00 CHANDRASHEKHAR
    Address
    WARD, BINA ETAWA, SAGAR, MADHYA PRADESH

    PIN 470113

    Police Station BINA

    Mobile/Tel No. 9340282494 / 8878949549

    E-mail VAISHALISH94@GMAIL.COM
    Permanent Residential Address
    RAJGHAT COLONY, DATIA, DATIA, MADHYA PRADESH,
    Address
    INDIA

    PIN 475661

    Police Station �H/��4O�2����

    Mobile/Tel No. 9340282494 / 8878949549


    Emergency Contact Details
    Name and Address NEELESH SHRIVATAVA

    Mobile/Tel No. 8878949549

    E-mail NEELSHRIVASTAVA10@GMAIL.COM
    Other Details
    Payment Details
    Mode of Payment UPI

    Date 11/11/2024

    Receipt/Reference No. CPAELFFJP8

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


    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 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.

    https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-0018019222 2/3
    11/11/24, 11:23 PM View/Print Submitted Form

    Place DATIA Signature/Left Hand Thumb Impression of


    Applicant (If applicant is minor, either parent
    Date 24/10/2024 to sign)

    https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-0018019222 3/3

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