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 Applying For Type of Application 13-1006354279 FRESH NORMAL

Type of Passport Booklet NORMAL Validity Required

Applicant Details
Applicant's Name Previous Name1 Date of Birth (DD/MM/YYYY) Place of Birth (Village/Town/City) District State/UT Country Gender Marital Status Citizenship of India by PAN Voter ID Employment Type ADHITHYA SRINIVASAN ADHITHAN 23/09/1993 KATCHANAGARAM VILLAGE NAGAPATTINAM TAMIL NADU INDIA MALE SINGLE BIRTH BFKPA4491K SWZ0938787 STUDENT Signature/Left Hand Thumb Impression of Illiterate Applicant and Minors who cannot sign.

Is either of your parent (in case of minor)/ spouse, a N government servant? Educational Qualification Are you eligible for NonECR category? 10TH PASS AND ABOVE Y

Visible Distinguishing Mark

A SCAR ON THE CHIN

Family Details
Father's Name Mother's Name SRINIVASAN KOTHANDARAMAN SEETHALAKSHMI SRINIVASAN

Present Address Details

Residing Since(MM/YYYY) Address PIN Mobile/Tel No Email 11/1998 34/20,PRABHA NAGAR,8TH ST,MC ROAD THANJAVUR TAMIL NADU THANJAVUR VALLAM 613004 9443247873 / 04362247873 SRINITNJ.S@GMAIL.COM S.SWAYAMPRAKASAM 31/17,8TH STREET, PRABHA NAGAR EXTENSION, MEDICAL COLLEGE ROAD, THANJAVUR-613004 04362247227 C.RAJENDRAN 48, PRABHA NAGAR EXTENSION, MEDICAL COLLEGE ROAD, THANJAVUR-613004 9791701381

First Reference Name And Address Mobile/Tel No Second Reference Name And Address Mobile/Tel No

Permanent Address
Address PIN Mobile/Tel No 34/20,PRABHA NAGAR,8TH ST,MC ROAD THANJAVUR TAMIL NADU THANJAVUR VALLAM 613004 9443247873 / 04362247873

Emergency Contact Details

Name and Address K.SRINIVASAN, 34/20, 8TH STREET, PRABHA NAGAR EXTENSION, MEDICAL COLLEGE ROAD, THANJAVUR 613004 9865395959 / 04362247873 SRINITNJ.S@GMAIL.COM

Mobile/Tel No Email

Other Details Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra)
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. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Self Declaration
I owe allegiance to the sovereignty, unity and 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 and I affirm that the information given by me in this form and the enclosures is true and I am solely responsible for its accuracy, and 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. Signature/Left Hand Thumb Impression of Applicant (If applicant is minor, either parent to sign)

Place THANJAVUR Date 25/06/2013