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This document is a passport application form for MD Muktafi Jalil, applying for a fresh normal jumbo passport. It includes personal details such as date of birth, address, and family information, along with a self-declaration affirming the accuracy of the provided information. The applicant is a male citizen of India, born in Kishanganj, Bihar, and has completed the 10th grade.

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2 views

View_Print Submitted Form

This document is a passport application form for MD Muktafi Jalil, applying for a fresh normal jumbo passport. It includes personal details such as date of birth, address, and family information, along with a self-declaration affirming the accuracy of the provided information. The applicant is a male citizen of India, born in Kishanganj, Bihar, and has completed the 10th grade.

Uploaded by

naushadf4u
Copyright
© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
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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 25-0002472190

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet JUMBO

Applicant Details

Applicant's Name MD MUKTAFI JALIL

Date of Birth (DD/MM/YYYY) 08/05/2004

Validity Required NA

Place of Birth (Village/Town/City) KISHANGANJ

District KISHANGANJ

State/UT BIHAR

Region/Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status SINGLE cannot sign.

Citizenship of India by BIRTH

PAN CNVPJ7053G

Employment Type SELF EMPLOYED

Is either of your parent (in case of


N
minor)/spouse, a government servant?

Educational Qualification 10TH PASS AND ABOVE

Are you eligible for Non-ECR category? Y

Family Details

Father's Name MD MINHAZ AKHTAR

Mother's Name SABINAZ BEGAM

Present Residential Address Details

Address A-15 RAHMAN HOUSE, KAMATI DHABAILI, KISHANGANJ, BIHAR

PIN 855101
Police Station TEDHAGACHH

Mobile/Tel No. 8750002196

E-mail [email protected]

Permanent Residential Address

Address A-15 RAHMAN HOUSE, KAMATI DHABAILI, KISHANGANJ, BIHAR

PIN 855101

Police Station TEDHAGACHH

Mobile/Tel No. 8750002196

Emergency Contact Details

Name and Address MD MINHAZ AKHTAR

Mobile/Tel No. 7837617217

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.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 KAMATI Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 11/02/2025 to sign)

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