5/11/23, 9:57 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 23-0008735210  
 
Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name RAJANIKANT BALVANTRAY PANDYA

Date of Birth (DD/MM/YYYY) 18/08/1966

Validity Required NA   

Place of Birth (Village/Town/City) BHAVNAGAR

District BHAVNAGAR

State/UT GUJARAT

Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.
 
Citizenship of India by BIRTH  
 
PAN AEEPP7783F

Employment Type GOVERNMENT

Organisation name PGVCL

Is either of your parent (in case of

Y
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 515398090857

Family Details
Father's Name BALVANTRAY JETHABHAI PANDYA

Mother's Name KAILASHBEN BALVANTRAY PANDYA

Spouse's Name HARSHABEN RAJANIKANT PANDYA

Present Residential Address Details
PLOT NO 52/C MAITRI, SUMERU TOWNSHIP, GAUSHALA,
Address
BHAVNAGAR, BHAVNAGAR, GUJARAT

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5/11/23, 9:57 PM View/Print Submitted Form

PIN 364001

Police Station BORTALAV

Mobile/Tel No. 9879616393

E-mail [email protected]
Permanent Residential Address
PLOT NO 52/C MAITRI, SUMERU TOWNSHIP, GAUSHALA,
Address
BHAVNAGAR, BHAVNAGAR, GUJARAT

PIN 364001

Police Station BORTALAV

Mobile/Tel No. 9879616393

Emergency Contact Details
HARSHABEN RAJANIKANT PANDYAPLOT NO 52/C MAITRI,
Name and Address
SUMERU TOWNSHIP, GAUSHALA

Mobile/Tel No. 09924095970

E-mail [email protected]
Other Details
Payment Details
Mode of Payment UPI

Date 11/05/2023

Receipt/Reference No. CPACSWCIQ7

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

Enclosures
1.Aadhaar Card/E-Aadhaar

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.

Place BHAVNAGAR Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 11/05/2023 to sign)

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