10/4/2019 View/Print Submitted Form

File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS

PASSPORT APPLICATION FORM

Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of the
application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original
documents at the time of submission of the form.

Service Required
Application Reference Number 19-1008060963

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name DIKSHIT RAJ PABATHI

Date of Birth (DD/MM/YYYY) 21/08/1998

Validity Required NA

Place of Birth (Village/Town/City) SECUNDERABAD

District HYDERABAD

State/UT TELANGANA

Country INDIA
Signature/Left Hand Thumb Impression
Gender MALE of Illiterate Applicant and Minors who
Marital Status SINGLE cannot sign.

Citizenship of India by BIRTH

PAN EXOPP7448N

Employment Type STUDENT

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

A MOLE ON RIGHT SIDE OF THE

Visible Distinguishing Mark
NECK

Aadhaar Number 869433280093

Family Details
Father's Name RAJ KUMAR PABATHI NAGAIAH
Present Residential Address Details
H.NO 6-1-344/12,BEHIND NTR STATUE,PADMARAO NAGAR,
Address
SECUNDERABAD, HYDERABAD, TELANGANA

PIN 500025

Police Station MUSHEERABAD

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10/4/2019 View/Print Submitted Form

Mobile/Tel No. 9704510653 / 9030710653

E-mail DIKSHITHRAJ98@GMAIL.COM
Permanent Residential Address
H.NO 6-1-344/12,BEHIND NTR STATUE,PADMARAO NAGAR,
Address
SECUNDERABAD, HYDERABAD, TELANGANA

PIN 500025

Police Station MUSHEERABAD

Mobile/Tel No. 9704510653 / 9030710653

Emergency Contact Details
Name and Address RAJ KUMAR

Mobile/Tel No. 9030710653

Payment Details
Mode of Payment Debit/Credit Card

Date 30/09/2019

Receipt/Reference No. CPV1210194

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)

Enclosures
1.Aadhaar Card/E-Aadhaar

2.Aadhaar Card/e-Aadhar containing the 12 digit Aadhaar number issued by the Unique Identification Authority of India(UIDAI)
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 SECUNDERABAD Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 22/08/2019 to sign)

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