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The document is a passport application form for Gul Dalal, applying for a reissue of her passport due to expiration over three years ago. It includes personal details, previous passport information, and a declaration of authenticity regarding the provided information. Payment for the application was made via UPI for an amount of Rs. 1500.

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4 views

Untitled 3

The document is a passport application form for Gul Dalal, applying for a reissue of her passport due to expiration over three years ago. It includes personal details, previous passport information, and a declaration of authenticity regarding the provided information. Payment for the application was made via UPI for an amount of Rs. 1500.

Uploaded by

gul dalal
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 25-0001065438

Applying For REISSUE

VALIDITY EXPIRED MORE THAN 3


If Re-issue, specify reason(s)
YEARS AGO

Type of Application NORMAL

Type of Passport Booklet NORMAL


Applicant Details
Applicant's Name GUL DALAL

Date of Birth (DD/MM/YYYY) 09/10/2001

Validity Required NA

Place of Birth (Village/Town/City) HISAR

District HISAR

State/UT HARYANA Signature/Left Hand Thumb Impression


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

Marital Status SINGLE

Citizenship of India by BIRTH

Employment Type STUDENT

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

Family Details
Father's Name SURENDER SINGH

Mother's Name SUSHILA


Present Residential Address Details
Address 2675 SECTOR 4, HISAR, HISAR, HARYANA

PIN 125001
Police Station CITY HISAR

Mobile/Tel No. 7733800088

E-mail [email protected]
Permanent Residential Address
Address 2675 SECTOR 4, HISAR, HISAR, HARYANA

PIN 125001

Police Station CITY HISAR

Mobile/Tel No. 7733800088


Emergency Contact Details
Name and Address SURENDER

Mobile/Tel No. 9813267018


Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M8714780

Date of Issue 11/05/2015

Date of Expiry 08/10/2019

Place of Issue CHANDIGARH

File Number CH1078738273215


Other Details
Payment Details
Mode of Payment UPI

Date 18/01/2025

Receipt/Reference No. CPAESCEYH6

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


Enclosures
1.Birth certificate issued by the Registrar of Births and Deaths or the Municipal Corporation or any other prescribed authority
whosoever has been empowered under the Registration of Birth and Deaths Act, 1969 to register the birth of a child born in India

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 HISAR Signature/Left Hand Thumb Impression of


Applicant (If applicant is minor, either parent
Date 18/01/2025 to sign)

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