2/6/2014 Application Form

https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 1/2
PASSPORT APPLICATION FORM
Government of INDIA, Ministry of External Affairs
Service Required
Application Reference Number 14-0005771510
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet JUMBO
Validity Required NA
Applicant Details
Applicant's Name ARJUN RAJENDRA PARMAR
Date of Birth (DD/MM/YYYY) 20/11/1988
Place of Birth (Village/Town/City) MUMBAI
District MUMBAI
State/UT MAHARASHTRA
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
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 THE FOREHEAD
Family Details
Father's Name RAJENDRA DHIRAJLAL PARMAR
Mother's Name SADHANA PARMAR
Present Address Details
Residing Since(MM/YYYY) 09/1989
Address
B-6 LIBERTY SHOPPING CENTRE HILL ROAD, MUMBAI, BANDRA
POLICE STATION, MUMBAI, MAHARASHTRA
PIN 400050
Mobile/Tel No. 9867425300 / 02226400105
E-mail PARMARARJUN_2007@HOTMAIL.COM
First Reference Name And Address
B-6 LIBERTY SHOPPING CENTRE HILL ROAD BANDRA WEST MUMBAI -
400050
Mobile/Tel No. 9867425300 / 02226400105
Second Reference Name And Address
B-4 LIBERTY SHOPPING CENTRE HILL ROAD BANDRA WEST MUMBAI -
400050
Mobile/Tel No. 9867425300 / 02226400105
Permanent Address
Address
B-6 LIBERTY SHOPPING CENTRE HILL ROAD, MUMBAI, BANDRA
POLICE STATION, MUMBAI, MAHARASHTRA
PIN 400050
Mobile/Tel No. 9867425300 / 02226400105
Emergency Contact Details
Name and Address ARJUN B-6 LIBERTY SHOPPING CENTRE HILL ROAD BANDRA WEST
Mobile/Tel No. 9867425300 / 02226400105
E-mail PARMARARJUN_2007@HOTMAIL.COM
Other Details
Self Declaration
I owe allegiance to the sovereignty, unity and integrity of India, and have not voluntarily acquired citizenship or travel
2/6/2014 Application Form
https://portal1.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction 2/2
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 MUMBAI
Date 02/06/2014