11/19/24, 7:44 AM 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 24-1014070319

Applying For REISSUE

VALIDITY EXPIRED WITHIN 3

YEARS/DUE TO EXPIRE. , CHANGE
If Re-issue, specify reason(s)
IN EXISTING PERSONAL
PARTICULARS

If change in existing personal

ADDRESS
particulars, specify

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name GOPAL GANDI

Date of Birth (DD/MM/YYYY) 02/02/1980

Validity Required NA Signature/Left Hand Thumb Impression

of Illiterate Applicant and Minors who
Place of Birth (Village/Town/City) SURYAPET cannot sign.
District SURYAPET

State/UT TELANGANA

Region/Country INDIA

Gender MALE

Marital Status MARRIED

Citizenship of India by BIRTH

Employment Type PRIVATE

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

Aadhaar Number 643237892895

Family Details
Father's Name PULLAIAH GANDI

Mother's Name SATYAMMA GANDI

Spouse's Name PREMALATHA GANDI

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11/19/24, 7:44 AM View/Print Submitted Form

Present Residential Address Details

153 ROAD NO 5 SYNERGY HOMES, TURKAYAMJAL,
Address
RACHAKONDA-RANGAREDDY, TELANGANA

PIN 501510

Police Station ADIBATLA

Mobile/Tel No. 9989515738

E-mail [email protected]
Permanent Residential Address
153 ROAD NO 5 SYNERGY HOMES, TURKAYAMJAL,
Address
RACHAKONDA-RANGAREDDY, TELANGANA

PIN 501510

Police Station ADIBATLA

Mobile/Tel No. 9989515738

Emergency Contact Details
Name and Address PREMALATHA

Mobile/Tel No. 9704629959

Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M3963777

Date of Issue 04/12/2014

Date of Expiry 03/12/2024

Place of Issue HYDERRABAD

File Number HY2077855267714

Other Details
Payment Details
Mode of Payment UPI

Date 19/11/2024

Receipt/Reference No. CPAELXFRZ7

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

Enclosures
1.PAN Card issued by the Income Tax Department

2.Aadhaar Card (Address Proof)

3.Affidavit stating how and where the Passport got lost/ damaged as per Annexure F
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.

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11/19/24, 7:44 AM View/Print Submitted Form

Place HYDERABAD Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 19/11/2024 to sign)

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