4/7/24, 9:02 PM View/Print Submitted Form

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 24-1004159443

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name NISHITH SINGH

Date of Birth (DD/MM/YYYY) 23/05/1987

Validity Required NA

Place of Birth (Village/Town/City) LUCKNOW

District LUCKNOW

State/UT UTTAR PRADESH

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

Citizenship of India by BIRTH

PAN DSSPS6228D

Employment Type PRIVATE

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

Visible Distinguishing Mark CUT ON THE LEFT EYEBROW

Family Details
Father's Name SATYA PRAKASH SINGH

Mother's Name BINDU SINGH

Present Residential Address Details
F1, 146/1 4TH CROSS PANDURANGANAGAR, BENGALURU,
Address
BENGALURU, KARNATAKA

PIN 560076

Police Station PUTTENAHALLI

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-1004159443 1/2
4/7/24, 9:02 PM View/Print Submitted Form

Mobile/Tel No. 9999879306

E-mail [email protected]
Permanent Residential Address
4/154 VIRAT KHAND GOMTI NAGAR, LUCKNOW, LUCKNOW,
Address
UTTAR PRADESH, INDIA

PIN 226010

Police Station GOMTI NAGAR

Mobile/Tel No. 9450644307

Emergency Contact Details
Name and Address SATYA PRAKASH SINGH

Mobile/Tel No. 9450644307

Other Details
Payment Details
Mode of Payment UPI

Date 29/03/2024

Receipt/Reference No. CPADRFJCP5

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

Enclosures
1.PAN Card issued by the Income Tax Department

2.Rent Agreement
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 BENGALURU Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 29/03/2024 to sign)

Print Close

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=24-1004159443 2/2