2/19/23, 10:42 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 23-1002239995
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name ANTARA SHEELAWANT
Date of Birth (DD/MM/YYYY) 22/12/1999
Validity Required NA
Place of Birth (Village/Town/City) BIJAPUR
District VIJAYAPURA
State/UT KARNATAKA
Region/Country INDIA
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 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? N
Aadhaar Number 601531345569
Family Details
Father's Name BASAVARAJ SHEELAVANT
Mother's Name ASHLESHA SHEELAVANT
Present Residential Address Details
WARD NO 12,PANCHAMRUTA BUILDING,MALAPRABHA NAGAR, OPP BLDE ENG
Address
COLLEGE,ASHRAM ROAD, VIJAYAPURA, KARNATAKA
PIN 586103
Police Station ADARSH NAGAR
Mobile/Tel No. 8073767688
E-mail [email protected]
Permanent Residential Address
WARD NO 12,PANCHAMRUTA BUILDING,MALAPRABHA NAGAR, OPP BLDE ENG
Address
COLLEGE,ASHRAM ROAD, VIJAYAPURA, KARNATAKA
PIN 586103
Police Station ADARSH NAGAR
Mobile/Tel No. 8073767688
Emergency Contact Details
BASAVARAJ SHEELAVANT,WARD NO 12,PANCHAMRUTA BLDG,MALAPRABHA
Name and Address
NAGAR,OPP BLDE ENG CLG,ASHRAM RD,VIJAYPURA
Mobile/Tel No. 9480780222
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
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 BANGALORE

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2/19/23, 10:42 PM Application Form
Date 19/02/2023

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