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 24-0003698396

Applying For REISSUE

VALIDITY EXPIRED MORE THAN 3

If Re-issue, specify reason(s) YEARS AGO , CHANGE IN EXISTING
PERSONAL PARTICULARS

If change in existing personal

ADDRESS
particulars, specify

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name SHASHIKANT RAJENDRA MARATHE

Date of Birth (DD/MM/YYYY) 04/12/1986

Validity Required NA
Signature/Left Hand Thumb Impression
Place of Birth (Village/Town/City) DONDAICHA
of Illiterate Applicant and Minors who
District DHULE cannot sign.

State/UT MAHARASHTRA

Region/Country INDIA

Gender MALE

Marital Status MARRIED

Citizenship of India by BIRTH

PAN AYTPM8662K

Voter Id ZLO8231060

Employment Type PRIVATE

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

Visible Distinguishing Mark BLACK SPOT ON LEFT TRICEP

Aadhaar Number 490134836729

Family Details
Father's Name RAJENDRA BAJIRAO MARATHE

Mother's Name KALPANA RAJENDRA MARATHE

Spouse's Name NEHA SHASHIKANT MARATHE

Present Residential Address Details
FLAT-303, HILL CREST SOCIETY, SUNIL NAGAR, SUS, PUNE,
Address
PUNE CITY, MAHARASHTRA

PIN 411021

Police Station CHATURSHRUNGI

Mobile/Tel No. 7387776126

E-mail [email protected]
Permanent Residential Address
FLAT-303, HILL CREST SOCIETY, SUNIL NAGAR, SUS, PUNE,
Address
PUNE CITY, MAHARASHTRA

PIN 411021

Police Station CHATURSHRUNGI

Mobile/Tel No. 7387776126

Emergency Contact Details
NEHA MARATHE, FLAT-303, HILL CREST SOCIETY, SUNIL
Name and Address
NAGAR, SUS, PUNE-411021

Mobile/Tel No. 9665042142

E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J5614865

Date of Issue 15/02/2011

Date of Expiry 14/02/2021

Place of Issue THANE

File Number THNZ07302610

Other Details
Payment Details
Mode of Payment UPI

Date 27/02/2024

Receipt/Reference No. CPADOIWHF6

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 PUNE Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 27/02/2024 to sign)

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