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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 Applying For Type of Application Type of Passport Booklet Validity Required 13-0007206836 FRESH NORMAL NORMAL

Applicant Details
Applicant's Name 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 Is either of your parent (in case of minor)/ spouse, a government servant? Educational Qualification Are you eligible for Non-ECR category? Aadhaar Number AXAYKUMAR JAGDISHBHAI PATEL 11/02/1992 KHERVA MEHSANA GUJARAT INDIA MALE SINGLE BIRTH BQUPP6302F YJT1591593 STUDENT N GRADUATE AND ABOVE Y 988323153163 Signature/Left Hand Thumb Impression of Illiterate Applicant and Minors who cannot sign.

Family Details
Father's Name Mother's Name JAGDISHBHAI JOITARAM PATEL CHANDRIKABEN JAGDISHBHAI PATEL

Present Address Details

Residing Since(MM/YYYY) Address 05/2007 AMBICANAGAR SOCIETY B/H GOVERNMENTHOSPITAL KHERVA GUJARAT MEHSANA KHERVA

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

382711 9737590145 AXAYPATEL11292@GMAIL.COM GOSWAMI AMITGIRI RAMESHGIRI, 1,AMBIKANAGAR SOCIETY, KHERVA 8866556606 PATEL FALGUNKUMAR JAYESHBHAI, PARAVAS, KHERVA 9033574336

Permanent Address
Address PIN Mobile/Tel No AMBICANAGAR SOCIETY B/H GOVERNMENTHOSPITAL KHERVA GUJARAT MEHSANA KHERVA 382711 9737590145

Emergency Contact Details

Name and Address Mobile/Tel No Email KEYUR PATEL AMBICANAGAR SOCIETY B/H GOVERNMENT HOSPITAL,KHERVA 9725845235 KEYURPATEL550@YAHOO.COM

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. Place Date KHERVA 11/06/2013 Signature/Left Hand Thumb Impression of Applicant (If applicant is minor, either parent to sign)

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