Professional Documents
Culture Documents
FRM Pass Lost
FRM Pass Lost
Example:
Surname: Pillai
Given name: Karur Vaikunta Subramaniyan Ramanathan
Since the length of the given name is more than 30 characters, it should be entered in the
following way:
Surname:
P I L L A I R AM A N A T H AN
Given name:
K A R U R V A I K U N T A S U B R A M A N I Y A N
º ÉÚSÉE {ÉjÉ / INDEX CARD
+É́ÉänE uÉ® É ¤ Écä +IÉ® Éå¨Éå¦É® É VÉÉB / To be filled by applicant in BLOCK LETTERS
1. {ÉÚ®É xÉÉ̈É (¸ÉÒ/¸ÉÒ̈ÉÊiÉ/EÖ̈ÉÉ® Ò) Full Name (Mr./Mrs./Miss):-
i. +É́ÉänE/ Applicant .............................................................................................
ii. Ê{ÉiÉÉ / Father ...................................................................................................
iii. ¨ÉÉiÉÉ / Mother ..................................................................................................
iv. {ÉÊiÉ/{ÉixÉÒ / Spouse ...........................................................................................
(+É́ÉänE BE ¡ Éä]Éä) (35 ×
45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ +Éè®
2. º lÉɪ ÉÒ {ÉiÉÉ / Permanent Address ...............................................................................
+É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ® ¡ Éä]Éä
......................................................................................................................
{É® +Éè® +ÉvÉä +É́ÉänxÉ {ÉjÉ {É®
......................................................................................................................
½ÉäxÉä SÉÉʽB*
............................................................................................................
Applicant must paste
(35 × 45 mm) one pho-
3. {ɽSÉÉxÉ EÉ ÊSÉx½ /Visible distinguishing marks .................................................................
tograph here with half
the signature on the
4. VÉx¨É º lÉÉxÉ /Place of birth ..........................................................................................
photograph and half on
the card.
3. EèÊ¡ ª ÉiÉ/Ê]{{ÉhÉÒ
Observation Remarks.................................
Ê{ÉxÉ EÉäc
PIN Code .............................................................................................................................
Serial No. PPT/98 FREE OF CHARGE
FORM NO. 3
¦ÉÉ® iÉ º É® EÉ®
(+É́ÉänE BE ¡ Éä]Éä) (35 ×
GOVERNMENT OF INDIA 45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ
Ê´Énä¶ É ¨ÉÆjÉɱ ɪ É +Éè® +É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ®
¡ Éä]Éä {É® +Éè® +ÉvÉä +É́ÉänxÉ
MINISTRY OF EXTERNAL AFFAIRS {ÉjÉ {É® ½ÉäxÉä SÉÉʽB*
MÉÖ̈É/IÉÊiÉOɺ iÉ {Éɺ É{ÉÉä]ÇEä ¤ Én± Éä ¨Éå Applicant must paste (35 ×
45 mm) one photograph
here with half the signature
10. (i) +É́ÉänE ¦ÉÉ® iÉ EÉ xÉÉMÉÊ® E ½è/ Applicant is a citizen of India by:
11. Cª ÉÉ +É́ÉänE xÉä {ɽ± Éä E¦ÉÒ +{ÉxÉÉ xÉÉ̈É ¤ Én± ÉÉ ½è, iÉÉä =º ÉEÉ ẾÉ́É® hÉ nå(ÊxÉnæ¶ É EÉ {Éè®É 7 näJÉå) / If the applicant ever changed his/her
name, give details : (See para 7 for instructions)
....................................................................................................................................................................
12. +É́ÉänE Eä{Éɺ É{ÉÉä]ǨÉå¶ ÉÉÊ̈ɱ É ÊEB VÉÉxÉä ´Éɱ Éä ¤ ÉSSÉÉåEÉ ẾÉ́É® hÉ / Particulars of children to be included in applicant's passport:
Name/xÉÉ̈É Date of Birth/VÉx¨É ÊiÉÊlÉ Place of Birth/ VÉx¨É º lÉÉxÉ Sex/˱ ÉMÉ
........................................................ ................................... ..................................... .........
........................................................ ................................... ..................................... .........
13. MÉÖ̈É/IÉÊiÉOɺ iÉ {Éɺ É{ÉÉä]Ç/ª ÉÉjÉÉ nº iÉÉ́ÉäVÉ EÉ ¤ ª ÉÉè®É / The details of Lost/Damage passport/travel document.
(E ) (i) {Éɺ É{ÉÉä]ÇEɪ ÉÉDZɪ É ¡ É<Ç±É xÉÆ0 / Passport Office File Number: ........................................................................
(ii) {Éɺ É{ÉÉä]Ç/ª ÉÉjÉÉ nº iÉÉ́ÉäVÉ º ÉÆJª ÉÉ / Passport/Travel Document Number ...........................................................
2
Transfer of Residence/Foreign Travel Scheme facility on Lost/Damaged passport ...........................................
14. Cª ÉÉ +É´ Éän E '=i|É´ Éɺ ÉxÉ VÉÉÆS É +É´ ɶ ª ÉE xÉ½Ó ½è' EÉ {ÉÉjÉ ½è? +MÉ® ½ÉÆ iÉÉä nº iÉÉ´ ÉäV É EÒ |ɨ ÉÉÊhÉiÉ |ÉÊiÉʱ ÉÊ{É
± ÉMÉÉ<ª Éä (ÊxÉnæ ¶ É EÉ {Éè® É 4 näJ Éå) ½ÉÄ Yes
Is applicant entitled for "Emigration Check Not Required (ECNR)?" If Yes, attach attested xÉ½Ó No
copy of the document (see para 4 of instructions)
15. Cª ÉÉ <º É̈Éå´ÉèvÉ ´ÉÒVÉÉ ½è?
Whether the passport contains valid visas? If yes, give details ........................................................................
16. 15. EÞ{ɪ ÉÉ ¤ ÉiÉÉBÆ ÊE Cª ÉÉ
Please Indicate whether :
(i) E¦ÉÒ +É{ÉEÉä {Éɺ É{Éä]Ç/ª ÉÉjÉÉ nº iÉÉ́ÉäVÉ näxÉä º Éä ¨ÉxÉÉ ÊEª ÉÉ Mɪ ÉÉ lÉÉ +lÉ́ÉÉ º ɶ ÉiÉÇ=xÉEÒ ¤ ɽɱ Ò EÒ Mɪ ÉÒ lÉÒ ½ÉÄ Yes
(i) A passport/travel document was refused/impounded at any time or restored xÉ½Ó No
conditionally.
(ii) +É́ÉänE EÉä º É® EÉ® Ò ± ÉÉMÉiÉ {É® nä¶ É |Éiª ÉÉ́ÉÐiÉiÉ ÊEª ÉÉ Mɪ ÉÉ lÉÉ ½ÉÄ Yes
(ii) The Applicant was repatriated at Government cost. xÉ½Ó No
(iii) Cª ÉÉ +É́ÉänE EÉä E¦ÉÒ |Éiª ÉÉ́ÉÐiÉiÉ ÊEª ÉÉ Mɪ ÉÉ lÉÉ ½ÉÄ Yes
(iii) The applicant was ever deported to India. xÉ½Ó No
17. {Éɺ É{ÉÉä]Ç+ÊvÉÊxɪ É̈É, 1967 EÒ vÉÉ® É 6 Eä +xiÉMÉÇiÉ +{ÉäÊIÉiÉ VÉÉxÉEÉ® Ò
Information required under section 6 of the Passport Act, 1967
(i) Cª ÉÉ ª ɽ +É́ÉänxÉ {ÉjÉ EÒ iÉÉ® ÒJÉ Eä `ÒE {ÉÉÆSÉ ´É¹ÉÇ{ɽ± Éä EÒ +´ÉÊvÉ ¨ÉåÊEº ÉÒ +{É® ÉÊvÉE VÉÖ̈ÉÇEä ʱ ÉB
ÊEº ÉÒ º É̈ɪ É ¦ÉÉ® iÉ Eä ÊEº ÉÒ xª Éɪ Éɱ ɪ É uÉ® É +É́ÉänE EÉä nÉä¹ÉÒ `½® ɪ ÉÉ Mɪ ÉÉ lÉÉ +Éè® EÉ® É́Éɺ É EÒ º ÉVÉÉ ½ÉÄ Yes
nÒ MÉ<ÇlÉÒ? xÉ½Ó No
(i) Has the applicant at any time during the period of five years immediately preceding the
date of this application been convicted by a Court in India for any criminal offence and
sentenced to imprisonment?
(ii) Cª ÉÉ ¦ÉÉ® iÉ E Ò ÊEº ÉÒ ¡ ÉèVÉnÉ® Ò +nɱ ÉiÉ ¨Éå+É́ÉänE Eä ẾÉ° r EÉä<ǨÉÖEn¨ÉÉ Sɱ É ® ½É ½è? ½ÉÄ Yes
(ii) Are any criminal proceedings pending against the applicant before a court in India? xÉ½Ó No
(iii) Cª ÉÉ ÊEº ÉÒ xª Éɪ Éɱ ɪ É uÉ® É xª Éɪ Éɱ ɪ É ¨Éå{Éä¶ É ½ÉäxÉä Eä´ÉÉ® h], º É̈¨ÉxÉ +lÉ́ÉÉ ÊMÉ® ~iÉÉ® Ò Eä ´ÉÉ® h] /¦ÉÉ® iÉ Eä ¤ Éɽ®
VÉÉxÉä EÒ ¨ÉxÉÉ½Ò Eä+Énä¶ É VÉÉ® Ò ÊEB Mɪ Éä ½é? ½ÉÄ Yes
(iii) Has a warrant or summons for appearance or warrant for arrest or an order prohibiting the xÉ½Ó No
applicant's departure from India been issued by a court?
18. +É́ÉänE EÒ PÉÉä¹ÉhÉÉ :
DECLARATION OF APPLICANT :
¨ÉÖZÉä ¦ÉÉ® iÉ EÒ º ÉÆ|ɦÉÖiÉÉ, BEiÉÉ +Éè® +JÉÆbiÉÉ Eä|ÉÊiÉ Êxɹ`É ½è+Éè® ¨ÉéxÉä º ´ÉäSUÉ º Éä ÊEº ÉÒ +xª É nä¶ É EÒ xÉÉMÉÊ® EiÉÉ {ÉÊ® iª ÉÉMÉ xÉ JÉÉä<Ç, xÉ ½Ò ¨ÉÖZÉä E¦ÉÒ
´ÉÆÊSÉiÉ ÊEª ÉÉ Mɪ ÉÉ ½è*
I owe allegiance to the sovereignty, unity & integrity of India and have not voluntarily acquired the citizenship or
travel document of another country. I have not lost, surrendered or been deprived of citizenship of India.
¨ÉéxÉä VÉÉä VÉÉxÉEÉ® Ò nÒ ½è´É½ º É½Ò ½è+Éè® =º ÉEÒ º Éiª ÉiÉÉ Eä ʱ ɪ Éä ¨Éå{ÉÚ®Ò iÉ® ½ º Éä ÊVÉ̈¨ÉänÉ® ½ÚÄ* ¨ÉÖZÉä <º É ¤ ÉÉiÉ EÒ VÉÉxÉEÉ® Ò ½è ÊE {Éɺ É{ÉÉä]Ç/nº iÉÉ́ÉäVÉ Eä ¤ ÉÉ® ä
¨ÉåZÉÚ̀Ò VÉÉxÉEÉ® Ò näxÉÉ/UÖ{ÉÉxÉÉ +{É® ÉvÉ ½è*
The information given by me is true and I am solely responsible for its accuracy. I am aware that it is an offence
under the Passports Act 1967 to furnish any false information or to suppress any material information with a view
to obtaining passport or any other travel document.
....................................................................
+É́ÉänE Eä ½º iÉÉIÉ® /+ÆMÉÚ̀äEÉ Êxɶ ÉÉxÉ
Signature/Thumb Impression of applicant
iÉÉ® ÒJÉ/ Date .......................... º lÉÉxÉ/ Place ........................
3
19. xÉɤ ÉÉʱ ÉMÉ EÒ Êº lÉÊiÉ ¨Éå¨ÉÉiÉÉ/Ê{ÉiÉÉ {Éɺ É{ÉÉä]ÇEä ¤ ÉÉ® ä ¨ÉåÊxÉ̈xÉʱ ÉÊJÉiÉ VÉÉxÉEÉ® Ò nå
In case of minors, following passport particulars of both parents must be given:
¨ÉÉiÉÉ / Mother Ê{ÉiÉÉ / Father
(a) {Éɺ É{ÉÉä]ÇxÉÆ0 / Passport No: .................................. ..............................
(b) VÉÉ® Ò ½ÉäxÉä EÒ iÉÉ® ÒJÉ / Date of Issue: .................................. ..............................
(c) VÉÉ® Ò ½ÉäxÉä EÉ º lÉÉxÉ / Place of Issue: .................................. ..............................
20. ª ÉÊn {Éɺ É{ÉÉä]Ç+´Éª ɺ E ´ª ÉÊCiÉ Eä ʱ ÉB ½è iÉÉä ¨ÉÉiÉÉ Ê{ÉiÉÉ +lÉ́ÉÉ +ʦɦÉÉ́ÉE EÒ PÉÉä¹ÉhÉÉ :
Declaration of Parent or Guardians if Passport is for minor :
¨Éé{ÉÖʹ] E® iÉÉ/E® iÉÒ ½ÚÄÊE ={ɪ ÉÖÇCiÉ ¤ ª ÉÉè®É EÉ (xÉÉ̈É) ........................................ {ÉÖjÉ/{ÉÖjÉÒ ¸ÉÒ .................................. ÊVɺ ÉEÉ ¨Éé
¨ÉÉiÉÉÊ{ÉiÉÉ/+ʦɦÉÉ́ÉE ½ÚÄEäº ÉƤ ÉÆvÉ ¨Éå½è* =º ÉEÉ {ÉÚ®É JÉSÉÇ=`ÉxÉäEÒÊVÉ̈¨ÉänÉ® ÒEÉ ´ÉSÉxÉ ± ÉäiÉÉ/± ÉäiÉÒ½ÚÄ* ¨ÉéÊxɹ`É{ÉÚ́ÉÇE PÉÉä¹ÉhÉÉ E® iÉÉ/E® iÉÒ½ÚÄÊE =º ÉxÉäE¦ÉÒ
+{ÉxÉÒ xÉÉMÉÊ® EiÉÉ xÉ½Ó JÉÉä<ǽè, =º ÉEÉ {ÉÊ® iª ÉÉMÉ xÉ½Ó ÊEª ÉÉ ½è+Éè® xÉ ½Ò =º Éä <º ɺ Éä E¦ÉÒ ´ÉÆÊSÉiÉ ÊEª ÉÉ Mɪ ÉÉ ½è+Éè® <º É +É́ÉänxÉ {ÉjÉ ¨Éå=º ÉEäº ÉƤ ÉÆvÉ ¨ÉånÒ
MÉ<ÇVÉÉxÉEÉ® Ò º É½Ò ½è*
we affirm that the particulars given above are in respect of (Name) ........................................................................
son/daughter of .............................................................................. of whom I am the Parent/Guardian. I undertake
the entire responsibility for his/her expenses. I solemnly declare that he/she has not lost, surrendered or been
deprived of his/her citizenship of India and that the information given in respect of him/her in this application is
true. It is also certified that the name of the child mentioned is not included in Passport of either parent.
23. +É́ÉänE xÉÒSÉä JÉɱ ÉÒ º lÉÉxÉÉå¨Éå+Éè® Êº ]E® Éå{É® EÞ{ɪ ÉÉ ½º iÉÉIÉ® +lÉ́ÉÉ +ÆMÉÚ̀ä Eä Êxɶ ÉÉxÉ Eä nÉä-nÉä xÉ̈ÉÚxÉånå*
Specimen signatures or Thumb Impressions of applicant in the boxes given below AND on two stickers.
4
´ÉèªÉÊCiÉE Ê´É́É® hÉ-{ÉjÉ (+É́ÉänE BE ¡ Éä]Éä) (35 ×
45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ
PERSONAL PARTICULARS FORM +Éè® +É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ®
¡ Éä]Éä {É® +Éè® +ÉvÉä +É́ÉänxÉ
(nÉä |ÉÊiɪ ÉÉå¨Éå¦É® å) {ÉjÉ {É® ½ÉäxÉä SÉÉʽB*
Applicant must paste (35 ×
(IN DUPLICATE) 45 mm) one photograph
here with half the signature
on the photograph and half
on the application.
5
8. ª ÉÊn +É́ÉänE ÊxÉnæ¶ É Eä {Éè®É (7) ¨ÉåÊnB MÉB {ÉiÉä {É® ± ÉMÉÉiÉÉ® MÉiÉ nÉä ´É¹ÉǺ Éä xÉ½Ó ® ½É ½èiÉÉä, EÞ{ɪ ÉÉ =xÉ º lÉÉxÉÉåEä {ÉiÉä +Éè® +´ÉÊvÉ nåVɽÉÆ <º É +´ÉÊvÉ
Eä nÉè®ÉxÉ ® ½É ½Éä* +É́ÉänE Bäº Éä |Éiª ÉäE +ÊiÉÊ® CiÉ º lÉÉxÉ Eä ʱ ÉB VɽÉÆ ´É½ ® ½É/® ½Ò ½Éä ´ÉèªÉÊCiÉE ẾÉ́É® hÉ {ÉjÉ EÉ BE +ÊiÉÊ® CiÉ º Éè] (¡ Éä]Éä ± ÉMÉÒ nÉä |ÉÊiÉ)
VÉ̈ÉÉ E® ɪ Éå* <º É =qä¶ ª É Eä ʱ ÉB ´ÉèªÉÊCiÉE ẾÉ́É® hÉ {ÉjÉ EÒ ¡ Éä]Éä EÉ{ÉÒ E® ´ÉÉ ± Éå*
If the applicant has not resided at the address given against para (7) continuously for the last two years, please
furnish the other address(es) with duration where he/she has resided during the period. Applicant should furnish
an additional set of Personal particulars form (in duplicate with photograph) for each additional place of stay
during the last two years. PP form may be photocopied for the purpose.
º É/äFrom........................ iÉE/to ..........................(ÊnxÉÉÆE / Date) º É/ä From ........................ iÉE/to ..............(ÊnxÉÉÆE/Date)
¨ÉEÉxÉ xÉÉ̈É/xÉÆ0 / House Name/No. ................................... ¨ÉEÉxÉ xÉÉ̈É/xÉÆ0 / House Name/No. ...........................
MÉÉÄ́É/Mɱ ÉÒ/ Vill./Street .................................................... MÉÉÄ́É/Mɱ ÉÒ/ Vill./Street ............................................
bÉEPÉ® / Post Office ....................................................... bÉEPÉ® / Post Office ...............................................
{ÉÖʱ ɺ É lÉÉxÉÉ / Police Station ............................................ {ÉÖʱ ɺ É lÉÉxÉÉ / Police Station ....................................
ÊVɱ ÉÉ / Distt. ................................................................ ÊVɱ ÉÉ / Distt. .........................................................
® ÉVª É / State .................................................................. ® ÉVª É / State ..........................................................
Ê{ÉxÉ EÉäb / PIN Code ................ Ê{ÉxÉ EÉäb / PIN Code .........
]ä± ÉÒ¡ ÉäxÉ º ÉÆ0 / Tel No. ..................................................... ]ä± ÉÒ¡ ÉäxÉ º ÉÆ0 / Tel No. ..............................................
9. º ÉÆn¦ÉÇ:- +{ÉxÉä IÉäjÉ Eä nÉä ÊVÉ̈¨ÉänÉ® ´ª ÉÊCiɪ ÉÉåEä xÉÉ̈É +Éè® {ÉiÉä nåVÉÉä +É{ÉEÒ VÉ̈ÉÉxÉiÉ ± Éä º ÉEiÉä ½Éå*
References:- Names and Addresses of two responsible persons in the applicant's locality who can vouch for the
applicant.
xÉÉ̈É / Name .......................................... 2. xÉÉ̈É /Name ...............................................................
{ÉiÉÉ / Address ....................................... {ÉiÉÉ /Address ............................................................
........................................................... ...............................................................................
........................................................... ...............................................................................
]ä± ÉÒ¡ ÉäxÉ xÉÆ0 / Telephone No. .................... ]ä± ÉÒ¡ ÉäxÉ xÉÆ0 /Telephone No. ..............................................
10. ¶ ÉÉ® ÒÊ® E ẾÉ0 / Physical Particulars:
(E/a) ± É̈¤ ÉÉ<Ç/ Height ....................... ¨ÉÒ]® /m ................. º Éä0 ¨ÉÒ0 /cm.
(JÉ) +ÉÄJÉÉåEÉ ® ÆMÉ (MÉ) ¤ Éɱ ÉÉåEÉ ® ÆMÉ
(b) Colour of eyes ..................................... (C) Colour of hair .........................
(PÉ) {ɽSÉÉxÉ EÉ |ÉE] ÊSÉx½
(d) Visible distiguishing mark .........................................................................................................
11. +É́ÉänE ¦ÉÉ® iÉ EÉ xÉÉMÉÊ® E ½è?
Applicant is a citizen of India by:
........................................................
¨ÉÉiÉÉ B´ÉÆ Ê{ÉiÉÉ/+ʦɦÉÉ́ÉE Eä ½º iÉÉIÉ® /+ÆMÉÚ̀ä Eä Êxɶ ÉÉxÉ
({ÉÖ¯¹É Eä ¤ ÉÉÆB +Éè® º jÉÒ Eä nÉBÆ ½ÉlÉ Eä +ÆMÉÚ̀ä EÉ Êxɶ ÉÉxÉ)
Signature or Thumb Impression of the
applicant (Left hand T.I. of male and
Right hand T.I. of female)
6
´ÉèªÉÊCiÉE Ê´É́É® hÉ-{ÉjÉ (+É́ÉänE BE ¡ Éä]Éä) (35 ×
45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ
PERSONAL PARTICULARS FORM +Éè® +É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ®
¡ Éä]Éä {É® +Éè® +ÉvÉä +É́ÉänxÉ
(nÉä |ÉÊiɪ ÉÉå¨Éå¦É® å) {ÉjÉ {É® ½ÉäxÉä SÉÉʽB*
Applicant must paste (35 ×
(IN DUPLICATE) 45 mm) one photograph
here with half the signature
on the photograph and half
on the application.
7
8a-2
8. ª ÉÊn +É́ÉänE ÊxÉnæ¶ É Eä {Éè®É (7) ¨ÉåÊnB MÉB {ÉiÉä {É® ± ÉMÉÉiÉÉ® MÉiÉ nÉä ´É¹ÉǺ Éä xÉ½Ó ® ½É ½èiÉÉä, EÞ{ɪ ÉÉ =xÉ º lÉÉxÉÉåEä {ÉiÉä +Éè® +´ÉÊvÉ nåVɽÉÆ <º É +´ÉÊvÉ
Eä nÉè®ÉxÉ ® ½É ½Éä* +É́ÉänE Bäº Éä |Éiª ÉäE +ÊiÉÊ® CiÉ º lÉÉxÉ Eä ʱ ÉB VɽÉÆ ´É½ ® ½É/® ½Ò ½Éä ´ÉèªÉÊCiÉE ẾÉ́É® hÉ {ÉjÉ EÉ BE +ÊiÉÊ® CiÉ º Éè] (¡ Éä]Éä ± ÉMÉÒ nÉä |ÉÊiÉ)
VÉ̈ÉÉ E® ɪ Éå* <º É =qä¶ ª É Eä ʱ ÉB ´ÉèªÉÊCiÉE ẾÉ́É® hÉ {ÉjÉ EÒ ¡ Éä]Éä EÉ{ÉÒ E® ´ÉÉ ± Éå*
If the applicant has not resided at the address given against para (7) continuously for the last two years, please
furnish the other address(es) with duration where he/she has resided during the period. Applicant should furnish
an additional set of Personal particulars form (in duplicate with photograph) for each additional place of stay
during the last two years. PP form may be photocopied for the purpose.
º É/äFrom........................ iÉE/to ..........................(ÊnxÉÉÆE / Date) º É/ä From ........................ iÉE/to ..............(ÊnxÉÉÆE/Date)
¨ÉEÉxÉ xÉÉ̈É/xÉÆ0 / House Name/No. ................................... ¨ÉEÉxÉ xÉÉ̈É/xÉÆ0 / House Name/No. ...........................
MÉÉÄ́É/Mɱ ÉÒ/ Vill./Street .................................................... MÉÉÄ́É/Mɱ ÉÒ/ Vill./Street ............................................
bÉEPÉ® / Post Office ....................................................... bÉEPÉ® / Post Office ...............................................
{ÉÖʱ ɺ É lÉÉxÉÉ / Police Station ............................................ {ÉÖʱ ɺ É lÉÉxÉÉ / Police Station ....................................
ÊVɱ ÉÉ / Distt. ................................................................ ÊVɱ ÉÉ / Distt. .........................................................
® ÉVª É / State .................................................................. ® ÉVª É / State ..........................................................
Ê{ÉxÉ EÉäb / PIN Code ................ Ê{ÉxÉ EÉäb / PIN Code .........
]ä± ÉÒ¡ ÉäxÉ º ÉÆ0 / Tel No. ..................................................... ]ä± ÉÒ¡ ÉäxÉ º ÉÆ0 / Tel No. ..............................................
9. º ÉÆn¦ÉÇ:- +{ÉxÉä IÉäjÉ Eä nÉä ÊVÉ̈¨ÉänÉ® ´ª ÉÊCiɪ ÉÉåEä xÉÉ̈É +Éè® {ÉiÉä nåVÉÉä +É{ÉEÒ VÉ̈ÉÉxÉiÉ ± Éä º ÉEiÉä ½Éå*
References:- Names and Addresses of two responsible persons in the applicant's locality who can vouch for the
applicant.
xÉÉ̈É / Name .......................................... 2. xÉÉ̈É /Name ...............................................................
{ÉiÉÉ / Address ....................................... {ÉiÉÉ /Address ............................................................
........................................................... ...............................................................................
........................................................... ...............................................................................
]ä± ÉÒ¡ ÉäxÉ xÉÆ0 / Telephone No. .................... ]ä± ÉÒ¡ ÉäxÉ xÉÆ0 /Telephone No. ..............................................
10. ¶ ÉÉ® ÒÊ® E ẾÉ0 / Physical Particulars:
(E/a) ± É̈¤ ÉÉ<Ç/ Height ....................... ¨ÉÒ]® /m ................. º Éä0 ¨ÉÒ0 /cm.
(JÉ) +ÉÄJÉÉåEÉ ® ÆMÉ (MÉ) ¤ Éɱ ÉÉåEÉ ® ÆMÉ
(b) Colour of eyes ..................................... (C) Colour of hair .........................
(PÉ) {ɽSÉÉxÉ EÉ |ÉE] ÊSÉx½
(d) Visible distiguishing mark .........................................................................................................
11. +É́ÉänE ¦ÉÉ® iÉ EÉ xÉÉMÉÊ® E ½è?
Applicant is a citizen of India by:
........................................................
¨ÉÉiÉÉ B´ÉÆ Ê{ÉiÉÉ/+ʦɦÉÉ́ÉE Eä ½º iÉÉIÉ® /+ÆMÉÚ̀ä Eä Êxɶ ÉÉxÉ
({ÉÖ¯¹É Eä ¤ ÉÉÆB +Éè® º jÉÒ Eä nÉBÆ ½ÉlÉ Eä +ÆMÉÚ̀ä EÉ Êxɶ ÉÉxÉ)
Signature or Thumb Impression of the
applicant (Left hand T.I. of male and
Right hand T.I. of female)
8
(+É́ÉänE BE ¡ Éä]Éä) (35 ×
45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ
8-A +Éè® +É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ®
FORM NO 3-A ¡ Éä]Éä {É® +Éè® +ÉvÉä +É́ÉänxÉ
(º ÉÉ® Ò |ÉÊiɪ ÉÉÆ +É́ÉänE uÉ® É ¦É® Ò VÉɪ ÉåMÉÒ) {ÉjÉ {É® ½ÉäxÉä SÉÉʽB*
Applicant must paste (35 ×
(All the copies to be filled in by applicant) 45 mm) one photograph
here with half the signature
on the photograph and half
on the application.
{ÉÖ¯¹É º jÉÒ
2. ˱ ÉMÉ / Sex
Male Female
iÉÉ® ÒJÉ ¨Éɽ ´É¹ÉÇ
3. VÉx¨É ÊiÉÊlÉ / Date of Birth
Date Month Year
9
8a-2
9. (E ) Cª ÉÉ +É́ÉänE Eä IÉÊiÉOɺ iÉ/MÉÖ̈É ½Éä Mɪ Éä {Éɺ É{ÉÉä]Ç{É® EÉä<Ç|ÉÊiɤ ÉÆvÉ lÉÉ, =º ÉEÉ ẾÉ́É® hÉ nå/ Details of restrictions, if any, on Lost/
Damaged passport .........................................................................................................................................
(JÉ) Cª ÉÉ +É́ÉänE xÉä MÉÖ̈É / IÉÊiÉOɺ iÉ {Éɺ É{ÉÉä]Ç{É® +É́Éɺ É {ÉÊ® ´ÉiÉÇxÉ / ẾÉnä¶ É ª ÉÉjÉÉ ª ÉÉäVÉxÉÉ EÉ ± ÉÉ¦É =`ɪ ÉÉ lÉÉ, iÉÉä ẾÉ́É® hÉ nå/ Details of
Transfer of Residence/Foreign Travel Scheme facility on Lost/Damaged passport ..........................................
10. |ÉlÉ̈É º ÉÚSÉxÉÉ Ê® {ÉÉä]Ç({ÉÖʱ ɺ É B¡ 0 +É<Ç0 +É® 0) / Copy of FIR .......................................................................................
11. +MÉ® '|É́Éɺ ÉÒ ¦ÉÉ® iÉÒª É' ½èiÉÉä +É́ÉänE E ¤ É º Éä ¤ Éɽ® ® ½ ® ½É ½è / If NRI, date from which the applicant residing abroad ......
....................................................................................................................................................................
........................................................................
+É́ÉänE Eä ½º iÉÉIÉ® / Signatures of Applicant
iÉÉ® ÒJÉ/ Date .....................................
To
The Director,
C.P.V. Division,
Patiala House,
Ministry of External Affairs,
New Delhi-110001
It is requested that clearance for issue of duplicate passport in lieu of Lost/Damaged (strike out what is not applicable)
passport be sent to us at the earliest in respect of individual whose particulars are given above.
...........................................................
Signatures of R.P.O./P.O.
...................................................
Signatures of Director (PV)
10
(+É́ÉänE BE ¡ Éä]Éä) (35 ×
45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ
8-A +Éè® +É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ®
FORM NO 3-A ¡ Éä]Éä {É® +Éè® +ÉvÉä +É́ÉänxÉ
(º ÉÉ® Ò |ÉÊiɪ ÉÉÆ +É́ÉänE uÉ® É ¦É® Ò VÉɪ ÉåMÉÒ) {ÉjÉ {É® ½ÉäxÉä SÉÉʽB*
Applicant must paste (35 ×
(All the copies to be filled in by applicant) 45 mm) one photograph
here with half the signature
on the photograph and half
on the application.
{ÉÖ¯¹É º jÉÒ
2. ˱ ÉMÉ / Sex
Male Female
iÉÉ® ÒJÉ ¨Éɽ ´É¹ÉÇ
3. VÉx¨É ÊiÉÊlÉ / Date of Birth
Date Month Year
11
8a-2
9. (E ) Cª ÉÉ +É́ÉänE Eä IÉÊiÉOɺ iÉ/MÉÖ̈É ½Éä Mɪ Éä {Éɺ É{ÉÉä]Ç{É® EÉä<Ç|ÉÊiɤ ÉÆvÉ lÉÉ, =º ÉEÉ ẾÉ́É® hÉ nå/ Details of restrictions, if any, on Lost/
Damaged passport .........................................................................................................................................
(JÉ) Cª ÉÉ +É́ÉänE xÉä MÉÖ̈É / IÉÊiÉOɺ iÉ {Éɺ É{ÉÉä]Ç{É® +É́Éɺ É {ÉÊ® ´ÉiÉÇxÉ / ẾÉnä¶ É ª ÉÉjÉÉ ª ÉÉäVÉxÉÉ EÉ ± ÉÉ¦É =`ɪ ÉÉ lÉÉ, iÉÉä ẾÉ́É® hÉ nå/ Details of
Transfer of Residence/Foreign Travel Scheme facility on Lost/Damaged passport ..........................................
10. |ÉlÉ̈É º ÉÚSÉxÉÉ Ê® {ÉÉä]Ç({ÉÖʱ ɺ É B¡ 0 +É<Ç0 +É® 0) / Copy of FIR .......................................................................................
11. +MÉ® '|É́Éɺ ÉÒ ¦ÉÉ® iÉÒª É' ½èiÉÉä +É́ÉänE E ¤ É º Éä ¤ Éɽ® ® ½ ® ½É ½è / If NRI, date from which the applicant residing abroad ......
....................................................................................................................................................................
........................................................................
+É́ÉänE Eä ½º iÉÉIÉ® / Signatures of Applicant
iÉÉ® ÒJÉ/ Date .....................................
To
The Director,
C.P.V. Division,
Patiala House,
Ministry of External Affairs,
New Delhi-110001
It is requested that clearance for issue of duplicate passport in lieu of Lost/Damaged (strike out what is not applicable)
passport be sent to us at the earliest in respect of individual whose particulars are given above.
...........................................................
Signatures of R.P.O./P.O.
...................................................
Signatures of Director (PV)
12
(+É́ÉänE BE ¡ Éä]Éä) (35 ×
45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ
8-A +Éè® +É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ®
FORM NO 3-A ¡ Éä]Éä {É® +Éè® +ÉvÉä +É́ÉänxÉ
(º ÉÉ® Ò |ÉÊiɪ ÉÉÆ +É́ÉänE uÉ® É ¦É® Ò VÉɪ ÉåMÉÒ) {ÉjÉ {É® ½ÉäxÉä SÉÉʽB*
Applicant must paste (35 ×
(All the copies to be filled in by applicant) 45 mm) one photograph
here with half the signature
on the photograph and half
on the application.
{ÉÖ¯¹É º jÉÒ
2. ˱ ÉMÉ / Sex
Male Female
iÉÉ® ÒJÉ ¨Éɽ ´É¹ÉÇ
3. VÉx¨É ÊiÉÊlÉ / Date of Birth
Date Month Year
13
8a-2
9. (E ) Cª ÉÉ +É́ÉänE Eä IÉÊiÉOɺ iÉ/MÉÖ̈É ½Éä Mɪ Éä {Éɺ É{ÉÉä]Ç{É® EÉä<Ç|ÉÊiɤ ÉÆvÉ lÉÉ, =º ÉEÉ ẾÉ́É® hÉ nå/ Details of restrictions, if any, on Lost/
Damaged passport .........................................................................................................................................
(JÉ) Cª ÉÉ +É́ÉänE xÉä MÉÖ̈É / IÉÊiÉOɺ iÉ {Éɺ É{ÉÉä]Ç{É® +É́Éɺ É {ÉÊ® ´ÉiÉÇxÉ / ẾÉnä¶ É ª ÉÉjÉÉ ª ÉÉäVÉxÉÉ EÉ ± ÉÉ¦É =`ɪ ÉÉ lÉÉ, iÉÉä ẾÉ́É® hÉ nå/ Details of
Transfer of Residence/Foreign Travel Scheme facility on Lost/Damaged passport ..........................................
10. |ÉlÉ̈É º ÉÚSÉxÉÉ Ê® {ÉÉä]Ç({ÉÖʱ ɺ É B¡ 0 +É<Ç0 +É® 0) / Copy of FIR .......................................................................................
11. +MÉ® '|É́Éɺ ÉÒ ¦ÉÉ® iÉÒª É' ½èiÉÉä +É́ÉänE E ¤ É º Éä ¤ Éɽ® ® ½ ® ½É ½è / If NRI, date from which the applicant residing abroad ......
....................................................................................................................................................................
........................................................................
+É́ÉänE Eä ½º iÉÉIÉ® / Signatures of Applicant
iÉÉ® ÒJÉ/ Date .....................................
To
The Director,
C.P.V. Division,
Patiala House,
Ministry of External Affairs,
New Delhi-110001
It is requested that clearance for issue of duplicate passport in lieu of Lost/Damaged (strike out what is not applicable)
passport be sent to us at the earliest in respect of individual whose particulars are given above.
...........................................................
Signatures of R.P.O./P.O.
...................................................
Signatures of Director (PV)
14
(+É́ÉänE BE ¡ Éä]Éä) (35 ×
45 Ê̈É0 Ê̈É0) ª ɽÉÆ ÊSÉ{ÉEÉBÆ
8-A +Éè® +É́ÉänE Eä +ÉvÉä ½º iÉÉIÉ®
FORM NO 3-A ¡ Éä]Éä {É® +Éè® +ÉvÉä +É́ÉänxÉ
(º ÉÉ® Ò |ÉÊiɪ ÉÉÆ +É́ÉänE uÉ® É ¦É® Ò VÉɪ ÉåMÉÒ) {ÉjÉ {É® ½ÉäxÉä SÉÉʽB*
Applicant must paste (35 ×
(All the copies to be filled in by applicant) 45 mm) one photograph
here with half the signature
on the photograph and half
on the application.
{ÉÖ¯¹É º jÉÒ
2. ˱ ÉMÉ / Sex
Male Female
iÉÉ® ÒJÉ ¨Éɽ ´É¹ÉÇ
3. VÉx¨É ÊiÉÊlÉ / Date of Birth
Date Month Year
15
8a-2
9. (E ) Cª ÉÉ +É́ÉänE Eä IÉÊiÉOɺ iÉ/MÉÖ̈É ½Éä Mɪ Éä {Éɺ É{ÉÉä]Ç{É® EÉä<Ç|ÉÊiɤ ÉÆvÉ lÉÉ, =º ÉEÉ ẾÉ́É® hÉ nå/ Details of restrictions, if any, on Lost/
Damaged passport .........................................................................................................................................
(JÉ) Cª ÉÉ +É́ÉänE xÉä MÉÖ̈É / IÉÊiÉOɺ iÉ {Éɺ É{ÉÉä]Ç{É® +É́Éɺ É {ÉÊ® ´ÉiÉÇxÉ / ẾÉnä¶ É ª ÉÉjÉÉ ª ÉÉäVÉxÉÉ EÉ ± ÉÉ¦É =`ɪ ÉÉ lÉÉ, iÉÉä ẾÉ́É® hÉ nå/ Details of
Transfer of Residence/Foreign Travel Scheme facility on Lost/Damaged passport ..........................................
10. |ÉlÉ̈É º ÉÚSÉxÉÉ Ê® {ÉÉä]Ç({ÉÖʱ ɺ É B¡ 0 +É<Ç0 +É® 0) / Copy of FIR .......................................................................................
11. +MÉ® '|É́Éɺ ÉÒ ¦ÉÉ® iÉÒª É' ½èiÉÉä +É́ÉänE E ¤ É º Éä ¤ Éɽ® ® ½ ® ½É ½è / If NRI, date from which the applicant residing abroad ......
....................................................................................................................................................................
........................................................................
+É́ÉänE Eä ½º iÉÉIÉ® / Signatures of Applicant
iÉÉ® ÒJÉ/ Date .....................................
To
The Director,
C.P.V. Division,
Patiala House,
Ministry of External Affairs,
New Delhi-110001
It is requested that clearance for issue of duplicate passport in lieu of Lost/Damaged (strike out what is not applicable)
passport be sent to us at the earliest in respect of individual whose particulars are given above.
...........................................................
Signatures of R.P.O./P.O.
...................................................
Signatures of Director (PV)
16