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9/8/24, 10:00 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 24-1011160623

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3


YEARS/DUE TO EXPIRE. , CHANGE
If Re-issue, specify reason(s)
IN EXISTING PERSONAL
PARTICULARS

If change in existing personal


ADDRESS , DELETE ECR
particulars, specify

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name ARSHAD BAIG MIRZA

Date of Birth (DD/MM/YYYY) 23/01/1995

Validity Required NA Signature/Left Hand Thumb Impression


of Illiterate Applicant and Minors who
Place of Birth (Village/Town/City) HYDERABAD cannot sign.
District HYDERABAD

State/UT TELANGANA

Region/Country INDIA

Gender MALE

Marital Status SINGLE

Citizenship of India by BIRTH

Employment Type OTHERS

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification 7TH PASS OR LESS

Are you eligible for Non-ECR category? Y

Family Details
Father's Name MIRZA AHMED BAIG

Mother's Name MOHAMMED BEGUM


Present Residential Address Details
H.NO:16-2-742/F/1/8/A, ASMANGADH,T.V TOWER,
Address
MALAKPET, HYDERABAD, TELANGANA

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-1011160623 1/2
9/8/24, 10:00 PM View/Print Submitted Form

PIN 500036

Police Station MALAKPET

Mobile/Tel No. 9346318951

E-mail [email protected]
Permanent Residential Address
H.NO:16-2-742/F/1/8/A, ASMANGADH,T.V TOWER,
Address
MALAKPET, HYDERABAD, TELANGANA

PIN 500036

Police Station MALAKPET

Mobile/Tel No. 9346318951


Emergency Contact Details
Name and Address MIRZA AHMED BAIG

Mobile/Tel No. 9849712898


Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M2264211

Date of Issue 17/09/2014

Date of Expiry 16/09/2024

Place of Issue HYDERABAD

File Number HY3067879858314


Other Details
Payment Details
Mode of Payment UPI

Date 08/09/2024

Receipt/Reference No. CPAEEUMTP9

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


Enclosures
1.PAN Card issued by the Income Tax Department

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 HYDERABAD Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 08/09/2024 to sign)

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-1011160623 2/2

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