11/21/23, 2:28 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 23-1013870293

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name ALLAMAPRABHU YECHHI

Date of Birth (DD/MM/YYYY) 04/06/1955

Validity Required NA

Place of Birth (Village/Town/City) BIJAPUR

District VIJAYAPURA

State/UT KARNATAKA

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 ATLPY5971A

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

Aadhaar Number 511862801339

Family Details
Father's Name RAJASHEKHAR YECHHI

Mother's Name SHARDA YECHHI

Present Residential Address Details
Address DHARI NILAYA,NEAR CHAITANYA HSPTL,JAI HANUMAN NA,

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11/21/23, 2:28 PM View/Print Submitted Form
VIJAYAPURA, VIJAYAPURA, KARNATAKA

PIN 586103

Police Station ADARSH NAGAR

Mobile/Tel No. 9902531992 / 8088857248

E-mail [email protected]
Permanent Residential Address
DHARI NILAYA,NEAR CHAITANYA HSPTL,JAI HANUMAN NA,
Address
VIJAYAPURA, VIJAYAPURA, KARNATAKA

PIN 586103

Police Station ADARSH NAGAR

Mobile/Tel No. 9902531992 / 8088857248

Emergency Contact Details
Name and Address KASHI BHUIN

Mobile/Tel No. 9900209298

Other Details
Payment Details
Mode of Payment UPI

Date 11/11/2023

Receipt/Reference No. CPADGETYH9

1350.00 (ONE THOUSAND THREE HUNDRED AND FIFTY

Amount Received (Rs.)
ONLY)
Enclosures
1.Aadhaar Card/E-Aadhaar

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 VIJAYAPURA Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 11/11/2023 to sign)

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