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Ayesha Bagwan Application Form

The document is a passport application form for Ayesha Sameer Bagwan, a female student born on October 17, 2004, from Belgaum, Karnataka, India. The application is for a fresh normal passport and includes personal, family, and residential details, as well as a self-declaration affirming the authenticity of the provided information. The form is dated April 17, 2025, and includes necessary enclosures such as a PAN card and Aadhaar card.

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Ayesha Bagwan
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4 views

Ayesha Bagwan Application Form

The document is a passport application form for Ayesha Sameer Bagwan, a female student born on October 17, 2004, from Belgaum, Karnataka, India. The application is for a fresh normal passport and includes personal, family, and residential details, as well as a self-declaration affirming the authenticity of the provided information. The form is dated April 17, 2025, and includes necessary enclosures such as a PAN card and Aadhaar card.

Uploaded by

Ayesha Bagwan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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4/17/25, 12:34 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External


Affairs

Service Required
Application Reference Number 25-0005595206
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name AYESHA SAMEER BAGWAN
Date of Birth (DD/MM/YYYY) 17/10/2004
Validity Required NA
Place of Birth (Village/Town/City) BELGAUM
District BELAGAVI CITY
State/UT KARNATAKA
Region/Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN HJGPB1306A
Employment Type STUDENT
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
Visible Distinguishing Mark NONE
Aadhaar Number 579276678715
Family Details
Father's Name SAMEER ABDULKADAR BAGWAN
Mother's Name ASMA SAMEER BAGWAN
Present Residential Address Details
C 21 D, BAHERCHAWADA, KUNKERI ROAD, SAWANTWADI,
Address
SINDHUDURG, MAHARASHTRA
PIN 416510
Police Station SAWANTWADI
Mobile/Tel No. 9405778690
E-mail [email protected]
Permanent Residential Address
C 21 D, BAHERCHAWADA, KUNKERI ROAD, SAWANTWADI,
Address
SINDHUDURG, MAHARASHTRA
PIN 416510
Police Station SAWANTWADI
Mobile/Tel No. 9405778690
Emergency Contact Details
Name and Address SAMEER BAGWAN, SAWANTWADI
Mobile/Tel No. 9890978604
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4/17/25, 12:34 PM Application Form

Other Details
Enclosures
1.Permanent Account Number Card issued by the Income-tax Department having the date of birth of the applicant
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 SAWANTWADI
Date 17/04/2025

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