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Passport Application Form Government of INDIA, Ministry of External Affairs

The document is a passport application form for Chingleima Kangjam from Manipur, India. It provides her personal details like name, date of birth, place of birth, parents' names and passport numbers. It also lists her current and permanent addresses in Imphal West, Manipur. The application is for a new normal passport and includes a self-declaration affirming her Indian citizenship and the accuracy of the information provided.

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Samrat
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83 views

Passport Application Form Government of INDIA, Ministry of External Affairs

The document is a passport application form for Chingleima Kangjam from Manipur, India. It provides her personal details like name, date of birth, place of birth, parents' names and passport numbers. It also lists her current and permanent addresses in Imphal West, Manipur. The application is for a new normal passport and includes a self-declaration affirming her Indian citizenship and the accuracy of the information provided.

Uploaded by

Samrat
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 18-0015657314
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name CHINGLEIMA KANGJAM
Date of Birth (DD/MM/YYYY) 03/08/2018
Validity Required NA
Place of Birth (Village/Town/City) IMPHAL
District IMPHAL WEST
State/UT MANIPUR
Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
Employment Type NOT EMPLOYED
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 7TH PASS OR LESS
Are you eligible for Non-ECR category? N
Family Details
Father's Name SAMRAT SINGH KANGJAM
Mother's Name BINAROY DEVI LEITANTHEM
Father/Legal guardian's File/Passport Number S2082603
Mother/Legal guardian's File/Passport Number S2076731
Present Residential Address Details
SEGA ROAD, NEAR TYC CLUB,KHWAIRAKPAM LEIKAI, IMPHAL WEST, IMPHAL,
Address
IMPHAL WEST, MANIPUR
PIN 795001
Mobile/Tel No. 9990606907
E-mail [email protected]
Permanent Residential Address
SEGA ROAD, NEAR TYC CLUB,KHWAIRAKPAM LEIKAI, IMPHAL WEST, IMPHAL,
Address
IMPHAL WEST, MANIPUR
PIN 795001
Mobile/Tel No. 9990606907
Emergency Contact Details
KANGJAM SAMRAT SINGH, SEGA ROAD KHWAIRAKPAM LEIKAI IMPHAL
Name and Address
WEST MANIPUR
Mobile/Tel No. 9990606907
E-mail [email protected]
Other Details
Enclosures
1.Birth Certificate issued by the Registrar of Births and Deaths or the Municipal Corporation or any other prescribed
authority,whosoever has been empowered under the Registration of Birth and Deaths Act, 1969 to register the birth of a child born in
India
2.Parent's passport copy, in case of minors(First and last page)
3.A declaration affirming the particulars furnished in the application about the minor as per Annexure D
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 IMPHAL WEST
Date 10/10/2018

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