12/25/24, 10:29 AM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-1015624271
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name BALAAMBIKA
Date of Birth (DD/MM/YYYY) 18/03/2001
Validity Required NA
Place of Birth (Village/Town/City) TIRUCHIRAPPALLI
District TIRUCHIRAPPALLI URBAN
State/UT TAMIL NADU
Region/Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN GCZPB7132P
Employment Type NOT EMPLOYED
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 481770199402
Family Details
Father's Name PERUMAL
Spouse's Name SENTHILKUMAR
Present Residential Address Details
NO 13 D GANDHI STREET JEEVA NAGAR, TIRUCHIRAPPALLI,
Address
TIRUCHIRAPPALLI URBAN, TAMIL NADU
PIN 620008
Police Station FORT
Mobile/Tel No. 7305367121
E-mail [email protected]
Permanent Residential Address
NO 13 D GANDHI STREET JEEVA NAGAR, TIRUCHIRAPPALLI,
Address
TIRUCHIRAPPALLI URBAN, TAMIL NADU
PIN 620008
Police Station FORT
Mobile/Tel No. 7305367121
Emergency Contact Details
Name and Address PERUMAL 13 D GANDHI STREET TRICHY
Mobile/Tel No. 9940956255
Other Details
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
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12/25/24, 10:29 AM Application Form
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 TIRUCHIRAPPALLI
Date 25/12/2024

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