Flenumber (For ores se On CH ‘GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS PASSPORT APPLICATION FORM Plo read the Passport Insucson Boot carefully bear fling the form. Fl ths fom in CAPITAL LETTERS using bluebook al poe pen ony, Fumieing ncaa nfraton! suppression of ineration wou eB orejcon ofthe appteaton an would stvact perl provisions a presebed unde he Passpre Al, 1987. Please produce your afi documents atthe ie of sbrision ofthe fe, Appleton Ratrnce Nunoer 00845002 oping Fr FRESH “ype ot Ageeaton NORMAL “ye ot Psspon Soot NORMAL estat yo tecononerame sepiearesNane ROWTHE tem taen Dat ot ODM) ‘siege ay Ronen Na Pace of Beh (WiageTowvciy) GUNTUR ame: ‘GUNTUR URBAN ResionCounry wow conser Mae ‘Signature/Left Hand Thumb i ic Marta Sas sInote ctitiete Arian anne who Cczeship af ns by eRTH moto Pan AavPess20R oer zrssaanie Employmant Type PsuOrganisation rare Is itor ot your parent reas of rnarispuse, «govenent servant? dues! ualfeston ‘oyu ale for Non ECR eslegay? ible Distinguishing Mark AadoaarNeeroar Family Details Present Residential Address Detalls does PIN Police Staton tel No Adees Potce Staton eile No Name and dese RITES TD [GRADUATE AND ABOVE [AMOLE ON THE FOREMEAD (RIGHT SIDE) 595216014251 [NELCO SOCIETY, NAGPUR CITY. MAHARASHTRA -ao02 RP NAGAR ‘9765769 (7755827199 ROHITHETICALA@GMAIL.COW FLAT NO 2068L.0CK V2,TNR SHAKUNTALA APTS 31-13, ‘SHVAPURI COLONY, CHINTALAKUNTA, RACHAKONGA- FRANGAREDDY, TELANGANA, INDIA 0007 LBNAGAR 799765769 /8979885556 'SHAKUNTALA APPTS, HNO. 3-1-418,P1N 500074, RAMULETICALA"T1764@QGMAL.COMode of Payment Debivcrest Card RecoipuRetrence No Paar. ‘aunt Received (Re) 1500.00 (ONE THOUSAND FIVE HUNORED ONLY) Enclosures 2.cetcate om Employer af teputed companies 2 tr hes ‘dently Cotfeatein egal a por Ames A 40 Objection Centeate NOC) pe Aanonue G ‘Pr Intron Let P98 per Anpone H Self Declaration owe aegance tthe sovereignty. unt & net ta, ard have ot vu acaued etzensip or ave acumen of any coer county. | have nol be, surendere a ben seprvad ofthe izes of, have not orravened any af the conor relating tthe possssion and uso ofan nian passport. | ati that the iforaon and prclare given by me nha form ate tue and cock urthar sat tat | ot suppressing ‘any mated nforaton in his regard | futher afm thatthe ensures and documentary poof sitesi uppot of my ‘appleaton for an nen passport re auhertic and sally pein o mead | am fly response for he accuracy of he same. ar Isle tobe ponsizad or posecte found othe am aware al under the Passparis Ae, 1967 tis a citi aflence o ‘msn any false information oo suppress any malarial nirmatonweh a veo blanng passer or travel document ‘have read and undid he contents af the above an by subiing hs orm cat tha a he tomato submited ya ‘ho form s boat, Poe NAGPUR Signature Hand Thumb Inptesion of Aeploant(fapctant i mina, thar parent ate vray tesign)