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 - 24-0047579118 Please paste
Applying For - FRESH your unsigned
Type of Application
Type of Passport Booklet -
- NORMAL
NORMAL
recent color
photograph of
size 4.5cm *
3.5cm.
Applicant Details
Applicant's Name - SHILPA GORAKHNATH CHAHARE
Date of Birth (DD/MM/YYYY) - 03/06/1999
Validity Required - NA
Place Of Birth
(Village/Town/City)
- CHANDRAPUR
District - CHANDRAPUR Signature/Left Hand Thumb Impression of
Illiterate Applicant and Minors who cannot
State/UT - MAHARASHTRA sign.
Region/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 - GRADUATE AND ABOVE
Are you eligible for Non-ECR
category
- Y
Aadhaar Number - 368544183098
Family Details
Father Name - GORAKHNATH CHAHARE
Mother Name - LAXMI CHAHARE
Present Residential Address Details:
Address - BHIWAPUR WARD, BACK OF RAJIV GANDHI COLLEGE, GAURIMOHALLA, CHANDRAPUR,
CHANDRAPUR, MAHARASHTRA
Pin - 442401
Police Station - CHANDRPUR CITY
Mobile/Tel No - 9175473699
Email - [email protected]
Permanent Residential Address Details
Address - BHIWAPUR WARD, BACK OF RAJIV GANDHI COLLEGE, GAURIMOHALLA, CHANDRAPUR,
CHANDRAPUR, MAHARASHTRA
Pin - 442401
Police Station - CHANDRPUR CITY
Mobile/Tel No - 9175473699
EmergencyContactDetails:
Name and Address - DIVYA CHAHARE
Mobile/Tel No. - 8421898836
Previous Passport
Have you ever applied for passport, but not issued?
File Number - BO2069578969024
Date of Issue - 23/04/2024
Name of passport office where applied - ANDHERI
Other Details
Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra/Passport Office)
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. Aadhaar Card (Address Proof)2. 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
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 - CHANDRAPUR Signature/Left Hand Thumb Impression of Applicant (If
Date - 25/05/2024 applicant is minor, either parent to sign)