4/4/24, 4:35 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 24-1004437021
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SIKHA CHAKRABORTY
Date of Birth (DD/MM/YYYY) 08/01/1964
Validity Required NA
Place of Birth (Village/Town/City) COOCHBEHAR
District COOCH BEHAR
State/UT WEST BENGAL
Region/Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN AQNPC5316J
Voter Id CBJ1311111
Employment Type HOME MAKER
Is either of your parent (in case of minor)/spouse, a
Y
government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 384309787743
Family Details
Father's Name MANINDRA NATH MAITRA
Mother's Name GOLAP MAITRA
Spouse's Name SUPRIYA CHAKRABORTY
Present Residential Address Details
Address SHUBHECHHA,NETAJI ROAD, CITY, COOCH BEHAR, WEST BENGAL
PIN 736101
Police Station KOTWALI
Mobile/Tel No. 9862332228
E-mail [email protected]
Permanent Residential Address
Address SHUBHECHHA,NETAJI ROAD, CITY, COOCH BEHAR, WEST BENGAL
PIN 736101
Police Station KOTWALI
Mobile/Tel No. 9862332228
Emergency Contact Details
SIKHA CHAKRABORTY,SHUBHECHHA,NETAJI ROAD,COOCHBEHAR,WEST
Name and Address
BENGAL
Mobile/Tel No. 9862332228
E-mail [email protected]
Other Details
Enclosures
1.Election Photo Identity Card (EPIC) issued by the Election Commission of India
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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4/4/24, 4:35 PM 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 COOCHBEHAR
Date 04/04/2024

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