1/12/2020 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 20-1000439211
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name USHA PRAKASH
Date of Birth (DD/MM/YYYY) 09/05/1971
Validity Required NA
Place of Birth (Village/Town/City) MANALURPET
District VILUPPURAM
State/UT TAMIL NADU
Country INDIA
Gender FEMALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN ABEPU0967B
Voter Id ABQ0387480
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark ONE MOLE IN RIGHT HAND SIDE ARM
Aadhaar Number 317975304628
Family Details
Father's Name ANNAMALAI SRIRAMULU
Mother's Name MUNIYAMMAL ANNAMALAI
Spouse's Name PRAKASH KRISHNAMOORTHY
Present Residential Address Details
NO 52B 1ST FLR 1ST MAIN ROAD NORTH JAGANATHA NAG, VILLIVAKKAM
Address
CHENNAI, CHENNAI, TAMIL NADU
PIN 600049
Police Station V-4 RAJAMANGALAM
Mobile/Tel No. 8807901978 / 4442819429
E-mail USHAPRAKASH6871@GMAIL.COM
Permanent Residential Address
NO 52B 1ST FLR 1ST MAIN ROAD NORTH JAGANATHA NAG, VILLIVAKKAM
Address
CHENNAI, CHENNAI, TAMIL NADU
PIN 600049
Police Station V-4 RAJAMANGALAM
Mobile/Tel No. 8807901978 / 4442819429
Emergency Contact Details
Name and Address E K PRAKASH
Mobile/Tel No. 8056084859 / 4442819429
E-mail EKPRAKASH68@GMAIL.COM
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number G7160695
Date of Issue 06/02/2008
Date of Expiry 05/02/2018
Place of Issue CHENNAI
File Number MASC00439008
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar

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1/12/2020 Application Form
2.Aadhaar Card/e-Aadhar containing the 12 digit Aadhaar number issued by the Unique Identification Authority of India(UIDAI)
3.Standard Affidavit as per Annexure E
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 CHENNAI
Date 12/01/2020

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