11/8/13 Application Form

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/2
PASSPORT APPLICATION FORM
Government of INDIA,Ministry of External Affairs
Service Required
Application Reference Number 13-1010103483
Applying For FRESH
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Validity Required NA
Applicant Details
Applicant's Name VISHNU PRASHANTH I
Date of Birth (DD/MM/YYYY) 17/10/1992
Place of Birth (Village/Town/City) CHENNAI
District CHENNAI
State/UT TAMIL NADU
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN ASFPV9584K
Employment Type STUDENT
Is either of your parent (in case of minor)/spouse, a
government servant?
N
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark SCAR ON RIGHT HAND ELBOW
Family Details
Father's Name INDRAMOHAN CV
Mother's Name REVATHI INDRAMOHAN
Present Address Details
Residing Since(MM/YYYY) 09/2009
Address
NO 12,BALAJI ROAD, KRISHNA NAGAR VELLORE TAMIL NADU
VELLORE SOUTH POLICE STATION
PIN 632001
Mobile/Tel No 9894052143 / 04162220988
E-mail VISHNUPRASHANTH.CVI@GMAIL.COM
First Reference Name And Address
INDRAMOHAN.CV 12,BALAJI ROAD, KRISHNA NAGAR, VELLORE-
632001
Mobile/Tel No 9944270409 / 04162220988
Second Reference Name And Address
LAKSHMI KUMAR.CV NO 12,BALAJI ROAD KRISHNA NAGAR, VELLORE-
632001
Mobile/Tel No 04162220988
Permanent Address
Address
NO 12,BALAJI ROAD, KRISHNA NAGAR VELLORE TAMIL NADU
VELLORE SOUTH POLICE STATION
PIN 632001
Mobile/Tel No 9894052143 / 04162220988
Emergency Contact Details
Name and Address
VISHNU PRASHNATH, NO 12,BALAJI ROAD,KRISHNA
NAGAR,VELLORE,632001
Mobile/Tel No 9894052143 / 04162220988
E-mail VISHNUPRASHANTH.CVI@GMAIL.COM
Other Details
11/8/13 Application Form
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 2/2
Self Declaration
I owe allegiance to the sovereignty, unity and 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 and I affirm that the information
given by me in this form and the enclosures is true and I am solely responsible for its accuracy, and 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.
Place VELLORE
Date 08/11/2013