10/6/22, 8:03 PM Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 22-0017088994
Applying For REISSUE
If Re-issue, specify reason(s) CHANGE IN EXISTING PERSONAL PARTICULARS
If change in existing personal particulars, specify GIVEN NAME , SPOUSE NAME , ADDRESS
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SATYAJEET NAGIN GUPTA
Previous Name1 SATYAJEET SATYAJIT
Date of Birth (DD/MM/YYYY) 13/11/1985
Validity Required NA
Place of Birth (Village/Town/City) MUMBAI
District MUMBAI
State/UT MAHARASHTRA
Region/Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN AONPG3984Q
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
Y
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? N
Visible Distinguishing Mark TATTOO ON LEFT HAND
Aadhaar Number 818847679522
Family Details
Father's Name NAGIN GUPTA
Mother's Name MALTI GUPTA
Spouse's Name TRISHTINA HEMBRAM
Present Residential Address Details
A404, LOKPRABHA CHSL, BUILDING NO. 124 SS NAGAR, TILAK NAGAR
Address
CHEMBUR, MUMBAI, MAHARASHTRA
PIN 400089
Police Station TILAK NAGAR
Mobile/Tel No. 8779063008
E-mail OFFICE.SATYAJEET@GMAIL.COM
Permanent Residential Address
A404, LOKPRABHA CHSL, BUILDING NO. 124 SS NAGAR, TILAK NAGAR
Address
CHEMBUR, MUMBAI, MAHARASHTRA
PIN 400089
Police Station TILAK NAGAR
Mobile/Tel No. 8779063008
Emergency Contact Details
Name and Address TRISHTINA HEMBRAM
Mobile/Tel No. 8850168643 / 7654240972
E-mail TRISHTIH@GMAIL.COM
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number J6351180
Date of Issue 08/03/2011
Date of Expiry 07/03/2021
Place of Issue THANE
File Number THNN01989510
Other Details
Enclosures

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10/6/22, 8:03 PM Application Form
1.Aadhaar Card/E-Aadhaar
2.Bank/ Kisan/ Post Office Passbooks
Self Declaration
I owe allegiance to the sovereignty, unity & 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. I have not contravened any of the conditions
relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not suppressing any
material information in this regard. I further affirm that the enclosures and documentary proof submitted in support of my application
for an Indian passport are authentic and solely pertain to me and I am fully responsible for the accuracy of the same. 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.
I have read and understood the contents of the above and by submitting this form certify that all the information submitted by me in
the form is bonafide.
Place MUMBAI
Date 06/10/2022
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