08/11/2024, 18:09 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-1013638055
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name AYRA BANERJEE
Date of Birth (DD/MM/YYYY) 27/09/2024
Validity Required NA
Place of Birth (Village/Town/City) KOLKATA
District KOLKATA
State/UT WEST BENGAL
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,
N
a government servant?
Educational Qualification 7TH PASS OR LESS
Are you eligible for Non-ECR category? N
Family Details
Father's Name ARNAB BANERJEE
Mother's Name AFROZA AFRIN PRIYA
Father/Legal guardian's File/Passport Number Z6539319
Present Residential Address Details
Address UKILPARA, PO & PS BARUIPUR, BARUIPUR, BARUIPUR, WEST BENGAL
PIN 700144
Police Station BARUIPUR
Mobile/Tel No. 8653311585
E-mail [email protected]
Permanent Residential Address
Address UKILPARA, PO & PS BARUIPUR, BARUIPUR, BARUIPUR, WEST BENGAL
PIN 700144
Police Station BARUIPUR
Mobile/Tel No. 8653311585
Emergency Contact Details
ARNAB BANERJEE, UKILPARA, PO & PS BARUIPUR, BARUIPUR, SOUTH 24
Name and Address
PGS., WEST BENGAL 700144
Mobile/Tel No. 7686994809
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 & 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 KOLKATA

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08/11/2024, 18:09 Application Form
Date 08/11/2024

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