View/Print Submitted Form https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftA...

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 19-1011314319

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name RAGUL ALAGIRISAMY

Date of Birth (DD/MM/YYYY) 07/11/1991

Validity Required NA

Place of Birth (Village/Town/City) BHILAI NAGAR

District DURG

State/UT CHHATTISGARH Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Country INDIA
cannot sign.
Gender MALE

Marital Status MARRIED

Citizenship of India by BIRTH

PAN AXRPR4879G

Voter Id SRB0585257

Employment Type PRIVATE

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 A SCAR ON LEFT FORE ARM

Aadhaar Number 639466632712

Family Details

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Father's Name ALAGIRISAMY

Mother's Name USHA

Spouse's Name SHANTHINI SELVAKUMAR

Present Residential Address Details
14/3 ASHOKA NAGAR WEST STREET, SHANMUGA NAGAR,
Address
ARUMBAKKAM, CHENNAI, L/�@ C@

PIN 600106

Police Station K-8 ARUMBAKKAM

Mobile/Tel No. 8056257258 / 9940053593

E-mail [email protected]
Permanent Residential Address
3/26, VINAYAGAR KOVIL STREET, SRI SAKTHI NAGAR,
Address
ARUMBAKKAM, CHENNAI, TAMIL NADU, INDIA

PIN 600106

Police Station K-8 ARUMBAKKAM

Mobile/Tel No. 8056257258 / 9940053593

Emergency Contact Details
Name and Address USHA

Mobile/Tel No. 9940053593 / 9940143608

E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J0867620

Date of Issue 02/08/2010

Date of Expiry 01/08/2020

Place of Issue CHENNAI

Payment Details
Mode of Payment Debit/Credit Card

Date 28/11/2019

Receipt/Reference No. CPW6570125

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

Enclosures
1.Aadhaar Card/E-Aadhaar

2.Proof of Gas Connection

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.

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Signature/Left Hand Thumb Impression of

Place CHENNAI Applicant (If applicant is minor, either parent
to sign)
Date 28/11/2019

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