Sample application form for Indian passport in USA

SAMPLE
IMMIHELP.COM
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POLAROID/INSTANT PHOTOS NOT
ACCEPTABLE
SL.No. EAPX- 1 -04
From No I External
GOVERNMENT OF INDIA
(APPLICATION FORM FOR INDIAN PASSPORT AT AN INDIAN MISSTON/POST)
(for the issue ofan ordinary international passport
Fresh / After l0 years (final) / and for duplicate
in lieu of lost / damaged passport
your unsigned
recent colour
Paste
photograph.
Size:2" X2"
tsokdF.
Specimen Signature
Payment of Fee (to be filled py gpplicant)
Amount paid $/E ........*. 3:.5.'..:.............. by..€.RJ.H.!.€8.....f.i1f,C.1s...... Mode of payment
For delivery by mail $/E ............ extra to be paid as postal charges for each passport'
l.
(a)
Full Name (expanded initials)
Surname, GUpTA
Given name R/AHUL
(b) Aliases, if any (Surname)
(c) applicant ever changed his/her name ? [s so, give previous name in full
RAHULKUMAR SURESHBHAI GUPTA
(d) Email
[email protected] PhNo 9725551212
id
2. Date of birth 05-DEC-1 975
9729998888
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Sex MALE
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Place of birth SURRT
Country
Height
SURAT GUJARAT
(cms.)
156
Color of Hair BLACK
Visible distinguishing marks, if any NIL
Colour of
eyes
3l'ii"lo"n
PARK AVENUE, APT A2
ALLEN' rx 75002
(i)
(ii)
N
Father
Mother
Name of
Country of his birth
Name of
Country of her birth
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SURESH GUPTA
INDIA
SARTTA GUPTA
INDIA
(iii) Nationality of Father at the time of applicant's
birth
INDIA
birth
INDIA
(iv) Nationality of Mother at the time of applicant's
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RAHUL GUPTA
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(b) Other Adress
423 SUDARSHAN SOCIETY
ADAJAN PATIA
SURAT 390 032
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3. Permanent Address :
(a) To be
134
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BLACK
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5.
Manied/Unmarried MARRIED
6. Name of Spouse MANISHA GUPTA
and
INDIA
7. Particulars of person to be intimated in the event of death or accident:
Nationality
Name ..... JYl.e..rtijfi.fl ....G .vI I k......
.. . .. I l. k . .. .P.M. ts...0rt fC. U f .,. . S/. L. fr..2.....
........0.
L.L. & N..,...2 r(..... ?.r0 0.. .f ............
.
Address
8. Present Passport/ nationality, identity card,
9. Local car driving Licence No.
10. Educational
25.SEP-2002
if any No. A99.7.Q9J9....Oate anO Place of issu. .+.|!Y.EP+.93P.
./:(..|.1.f.1..r1........
Date and Place of issue
......9..?.:.? €.C.:..?.Q.t.
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qualification BE
(In order to determine emigration status).
11.
12.
whendidapplicantfirst leavelndia?
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How long has applicant continuously resided abroad?
13. Present Emigration Status (ECR or ECNR)
(With documentary evidence)
S of r
ECR
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Bb, Piana
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t4. Profession and business
Duslness address
aooress ---|.+
15. Please mention,
16.
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FUG*lqq'7 whenwashe/she inlndia ,urr,
Tetenhc
(q7z) sSf- tzr L
if citizen of India by birth/descent/nationalization/Registration. E t ef
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Did applicant ever possess any other nationality or travel document of any other country? If so please
give
detaits
r\r
(Yes@
17. Was applicant ever refused an Indian Passport?
18. Was applicant'passport ever impounded/revoked?
If
so, details please.
19. Name and address of two relatives/friends
NrLr-
(l)
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(2)
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I SAN^ A AYBUAV A}
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60O
20. Is applicant in Govt. Service/Public Undertaking Service/Statutory Bodies Service of India?
:: ::::: :l: :::::l: ::: :::l::: ): ::t:::i::
::i:::::
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21. (i) Are any criminal proceedings pending against applicant in any court in India? So, please
give ditaits
......... ......N0'.
(ii) Has applicant ever been repahiated frolqabroad to India at the expenses of the Govt. of
India ? If so, details please. ... .hJ. U
22. No. of lost/damaged
Date of issue
.
passport
0
f.l.q-........ place of issue
...... Valid until
.
If
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23. (i) Briefly state circumstances of loss/thefl/damage of passport on a plain paper and attach
copy of report lodged with local police in case of loss/theft
(ii)
Give details of restriction, if any, put on applicants's damaged/lost passport.
(iii) Did applicant avail transfer of residence, foreign travel
passport ? if so, details please
24. Is applicant registered with Indian Mission/Post ?
Organisation
If
scheme facility on lost/damaged
not, is he a member of any Indian
N0
?
25. Particulars of children, if any, to be
Name
deleted
N
i A-
Place
(MiF)
& Date of birth
Note : Separate passport will be issued to children of all ages. However, children below
l8 years of age will be given a 5-year maximum validity passport
26. DECLARATION
:
I owe allegiance to the sovereignty, unity & integrity of India and have not voluntarily acquired the
citizenship or travel document of another country. I have not lost, surrendered or been deprived of
citizenship of India.
The information given by me is true and I am solely responsible for its accuracy. I am aware that it is an
offence under the Passport Act,1967 to fumish any false information or to suppress any material
information with a view to obtaining passport or any other travel document.
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Signature/Thumb Impression of applicant
(Left Hand T.l. if male and right Hand T.l. if female)
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Passport No.
:
(b) Dateof Issue:l-Tl
m
(c) Place of Issue:
(d) Ifparents have applied for
A passport, please give
File No
&
date
[TTn
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of minors, following passport particulars of both parents must be given:
Mother
(a)
:.:.!.'..k*,. ....A.t
N
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a
Father
f
2SDeclaration of Parents or Guardian if passport is for minor : (To be signed by both Parents or Guardian)
We affirm that the particulars given above are in respect of (Name)
......Sh.
Son / daughter of Smt.
of whom we are the Parents / Guardian. We undertake the entire responsibility for his/her expenses. We
solemnly declare that he/she has not lost, surrendered or been deprived of his/her citizenship of lndia and
that the information given in respect of him/her in this application is true. It is also certified that the name
of the child mentioned is not included in passport of either parent.
N
Mother
Name
Father
Guardian
& Signature/ T.l of both the Parents/Guardian (left hand T.l. if male and Right
29. Specimen signature or T.l.within the Space given below
gFw0Y1pil{'tA
(o
hand
T.l .if female)
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FOR OFFICE USE ONLY
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