PERFORMA FOR VERIFICATION OF NATIONALITY

STATUS/ANTECEDENTS
(PLEASE TYPE OR
PRINT)

1. FULL NAME:
2. ALIASES, IF ANY:
3. (a) FULL NAME OF
FATHER:
(b) FULL NAME OF
MOTHER:
(c) FULL NAME OF
4. SPOUSE:
DATE AND PLACE OF
BIRTH:
5. PRESENT OCCUPATION:
6. NATIONALITY:
Whether holds dual
nationality,
(If so, both the nationalities
to
be clearly mentioned)
7. PRESENT ADDRESS IN
USA

(DD-MM-YYYY)
(DISTRICT)

(VILLAGE)

Telephone No. __________________ Email:

_________________________________________
8. COMPLETE PERMANENT ADDRESS IN INDIA:

9. DETAILS OF PASSPORT:
ISSUE:

PASSPORT NO:

PLACE OF ISSUE:
10. VISBILE DISTINGUISHING MARKS IF ANY:
11. DATE OF LEAVING INDIA:
12. PERIOD OF STAY
ABROAD:
13. DATE OF LOSS OF
PASSPORT:
14. NAME & ADDRESS OF
(1)
TWO
RELATIVES / FRIENDS (AT
PLACE
THE OF PERMANENT RESIDENCE IN

_ DATE OF
DATE OF EXPIRY:

(2)

INDIA, Given In Sr.8 Above, Not of the same

family)

15. NAME & ADDRESS OF

TRAVEL
AGENT INVOLVED IN
SENDING
THE INDIVIDUAL ABROAD
NOTE: Please complete all entries legibly and fully: Incomplete Information will only lead to delay in the process of issuing
passport.

_________________________
(Signature)