12/1/23, 8:13 AM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 23-1014663925
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SUMANTH SALAGRAM
Date of Birth (DD/MM/YYYY) 11/03/2001
Validity Required NA
Place of Birth (Village/Town/City) MAHADEVPUR
District JAYASHANKAR BHUPALPALLY
State/UT TELANGANA
Region/Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN LSTPS4863F
Voter Id IXW7170244
Employment Type NOT EMPLOYED
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 611386357290
Family Details
Father's Name SRINIVAS SALAGRAM
Mother's Name KRISHNAVENI SALAGRAM
Present Residential Address Details
4-121,BRAHMANAVADA, MAHADEVPUR, JAYASHANKAR BHUPALPALLY,
Address
TELANGANA
PIN 505504
Police Station MAHADEVPUR
Mobile/Tel No. 9705948753
E-mail [email protected]
Permanent Residential Address
4-121,BRAHMANAVADA, MAHADEVPUR, JAYASHANKAR BHUPALPALLY,
Address
TELANGANA
PIN 505504
Police Station MAHADEVPUR
Mobile/Tel No. 9705948753
Emergency Contact Details
SALAGRAM SUMANTH, 4-121,MAHADEVPUR, JAYASHANKAR
Name and Address
BHUPAPALLY, TELANGANA
Mobile/Tel No. 9705948753
E-mail [email protected]
Other Details
Enclosures
1.PAN Card issued by the Income Tax Department
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.

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12/1/23, 8:13 AM Application Form
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 MAHADEVPUR
Date 01/12/2023

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