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The document is a passport application form for Prajakta Rajesh Patil, applying for a fresh TATKAAL passport. It includes personal details such as date of birth, address, family information, and payment details. The applicant affirms the accuracy of the information provided and acknowledges the legal implications of false information under the Passports Act, 1967.

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patilrajesh1001
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3 views

View_Print Submitted Form

The document is a passport application form for Prajakta Rajesh Patil, applying for a fresh TATKAAL passport. It includes personal details such as date of birth, address, family information, and payment details. The applicant affirms the accuracy of the information provided and acknowledges the legal implications of false information under the Passports Act, 1967.

Uploaded by

patilrajesh1001
Copyright
© © All Rights Reserved
Available Formats
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 24-0020851252

Applying For FRESH

Type of Application TATKAAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name PRAJAKTA RAJESH PATIL

Date of Birth (DD/MM/YYYY) 02/11/1998

Validity Required NA

Place of Birth (Village/Town/City) BARAMATI

District PUNE RURAL

State/UT MAHARASHTRA

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

Citizenship of India by BIRTH

Employment Type OTHERS

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? N

Aadhaar Number 589289799256

Family Details
Father's Name VIJAYSINH ANANDRAO EJAGAR

Mother's Name KALPANA VIJAYSINH EJAGAR

Spouse's Name RAJESH POPAT PATIL


Present Residential Address Details
FLAT-409, A BUILDING, MAJESTIQUE NEST, FURSUNGI,
Address
PUNE CITY, MAHARASHTRA

PIN 412308

Police Station HADAPSAR


Mobile/Tel No. 9607231001

E-mail [email protected]
Permanent Residential Address
LANDE WASTI, DEWADE, DEWADE, SOLAPUR RURAL,
Address
MAHARASHTRA, INDIA

PIN 413304

Police Station KARKAMB

Mobile/Tel No. 9607231001


Emergency Contact Details
Name and Address RAJESH PATIL

Mobile/Tel No. 9970671001

E-mail [email protected]
Other Details
Payment Details
Mode of Payment UPI

Date 17/12/2024

Receipt/Reference No. CPAEOTAUU6

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)


Enclosures
1.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognized educational board

2.Electricity Bill
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 FURSUNGI Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 17/12/2024 to sign)

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