6/1/2018 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 18-0008396716
Applying For FRESH
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name RAGHAV JETHLIYA
Date of Birth (DD/MM/YYYY) 26/10/1996
Validity Required NA
Place of Birth (Village/Town/City) INDORE
District INDORE
State/UT MADHYA PRADESH
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN BROPJ9437N
Employment Type STUDENT
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? N
Aadhaar Number 929170164802
Family Details
Father's Name DINESH KUMAR JETHLIYA
Mother's Name VINITA JETHLIYA
Present Residential Address Details
FLAT NO.415-A, TRISHLA APARTMENT, BIYABANI, INDORE, CHHATRIPURA,
Address
INDORE, MADHYA PRADESH
PIN 452002
Mobile/Tel No. 8462851865
E-mail RAGHAVMAHESHWARI.905@REDIFFMAIL.COM
Permanent Residential Address
FLAT NO.415-A, TRISHLA APARTMENT, BIYABANI, INDORE, CHHATRIPURA,
Address
INDORE, MADHYA PRADESH
PIN 452002
Mobile/Tel No. 8462851865
Emergency Contact Details
DINESH JETHLIYA, FLAT NO. 415-A, TRISHLA APARTMENT, BIYABANI,
Name and Address
INDORE
Mobile/Tel No. 9977899289
E-mail MADDYMADHAV222@GMAIL.COM
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Rent Agreement
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 INDORE
Date 01/06/2018

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