12/9/24, 11:09 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 24-0020456162

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name SWAPNIL PANDEY

Date of Birth (DD/MM/YYYY) 09/02/1991

Validity Required NA

Place of Birth (Village/Town/City) FIROZABAD

District FIROZABAD

State/UT UTTAR PRADESH Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Region/Country INDIA cannot sign.
Gender MALE

Marital Status MARRIED

Citizenship of India by BIRTH

PAN BZCPP1750L

Employment Type PRIVATE

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Visible Distinguishing Mark T MARK ON LEFT FOREHEAD

Aadhaar Number 830938228943

Family Details
Father's Name SUDHIR KUMAR PANDEY

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Mother's Name VEENA PANDEY

Spouse's Name SHALINI PANDEY

Present Residential Address Details
15/3, VIBHAV NAGAR, FIROZABAD, FIROZABAD, UTTAR
Address
PRADESH

PIN 283203

Police Station KOTWALI UTTAR (NORTH)

Mobile/Tel No. 8377837465

E-mail [email protected]
Permanent Residential Address
15/3, VIBHAV NAGAR, FIROZABAD, FIROZABAD, UTTAR
Address
PRADESH

PIN 283203

Police Station KOTWALI UTTAR (NORTH)

Mobile/Tel No. 8377837465

Emergency Contact Details
Name and Address SHALINI PANDEY

Mobile/Tel No. 7617707860

E-mail [email protected]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M9125259

Date of Issue 21/05/2015

Date of Expiry 20/05/2025

Place of Issue BAREILLY

File Number BL05Z0036118112

Other Details
Payment Details
Mode of Payment UPI

Date 09/12/2024

Receipt/Reference No. CPAENXTNX5

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

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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 FIROZABAD Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 09/12/2024 to sign)

Print Close

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