oken No.

N 234
Page 1 of 3
Counter No.A5 -Confdential-
28/12/2022 Wed 14:36:099 co3074916656922
CSE PSP22904
ARN: 22-1015074471

PASSPORT APPLICATION FORM

External Affairs
Government of INDIA, Ministry of
gnature/
(within the
Left Hand Thumb
Impression of Applicant
designated box only)

Service Required
Applying for REISSUE
If
re-issue., specify reason(s) Validity Expired within 3 years/ Due to Expire
Type of Application
NORMAL
Type of
Passport Booklet JUMBO
Applicant Details
Applicant's Given Name VIJAI
Applicant's Surname ABRAHAM
Date Of Birth
(DD/MMYYYY) 21/05/1973
Place Of Birth
KOTHAMANGALAM
District, State/UT, Country
ERNAKULAM RURAL KERALA,INDIA
Gender
MALE
Marital Status MARRIED

Citizenship of India By BIRTH

PAN AFGPV0364P

Employment Type OTHERS

s either of your parent(if minor)/spouse,a government servant? N
GRADUATE AND ABOVE
Education Qualification
Eligible for Non-ECR category?
BLACK MOLE ON LOWER JAW
Visible Distinguising Mark
978895215487
Aadhaar Number

Family Details

Father's Name ABRAHAM VARGHESE

Mother's Name MARY ABRAHAM
Spouse's Name JEEJAVIJAL
R e s i d e n t i a l Address
Details
Present

Address
MULAYIRIKKAL, GRACE VILLA
NORTH PARAVOOR P.0.ERNAKULAM RURAL
PIN:683513,KERALA,INDIA
NORTH PARAVOOR
Police Station
9746910941
Mobile/Telephone Number

vijalabraham@yahoo.co.in
E-mail D
Address Details
Residential
Permanent
MULAYIRIKKAL, GRACE VILLA, NORTH PARAVoOR P.O, ERNAKULAM RURAL. NORTH PARAVOOR,
Address 683513

PIN
Mobile/Telephone Number
9746910941
ARN: 22-1015074471
28/12/2022 Wed 14:36:09
-Confidential- -Page 2 of 3-

Emergency Contact Details

Name and Address
PAUL ABRAHAM, GRACE VILLA, MULAYIRIKKAL, PERUMPADANNA, NORTH PARAVOOR, KERALA-INDL
DIA
683513
Mobile/Telephone Number 9961169715
Email
Details of latest sumatv@yahoo.com
Passport Number held/existing/lost/damaged ordinary passport
File Number Z1997154
Date of Issue Co3071768906713
Date of Expiry 21/01/2013
20/01/2023
Place of Issue
Have you
coCHIN
ever applied for passport, but not issued?
Enclosure List
N
Declarations POB -PPT: POA - PPT:
Other Details
Self Declaration
owe aiegance to the sovereignty, unity & integrity of India, and have not voluntarily acquired citizenship or travel document of any other
lost, surrendered or been deprived conditions relating to
country.have not
the possession and use of an Indian
of the
citizenship of India. I have not contravened any ofthe
passport.
a i m that the infomation 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 en
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 penaized
or prosecuted If found otherwise. l 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.

Ihave read and understood the contents ofthe above and by submitting this fom certifty that all the information submitted by me in the form
is bonafide.
I hereby confirm that all documents including original and photocopies thereof have been handed over back to me post digitization of

required documents.
Furthermore, I solemnly affirm that:
before any Court of Law in
I have not been charged with criminal proceedings nor is there any arrest warrant or summon pending India

against me.
the date of this applicauon,
I have not been convicted by any Court of Law in India for anv

**During the 5 years immediately preceding

for two years or more.
criminal offence and sentenced to imprisonment
denied passport nor passport has been impounded orrevoked.
my
I have neither refused or
I ever granted political asylum by any foreign country.
applied for, nor was
**Ihave never or repatriated to India,
returned to India on Emergency Certificate nor waslever deported
**I have never
dated 21/01/2013 ISSued DyKFOEmbassy of Indla/Consulate General ofIndia duly
is d h
Number Z1997154
M y Previous Passport having cancelled passport.
of my
cancelled and I acknowledge the receipt
 015074471
-Confidenti -Page 3 of 3-
NORTH PARAVOOR 28/12/2022 Wed 14:36:09

Date
28/12/2022 Signaturel Left Hand Thumb
Impression of Applicant(f
applicant is minor, either
parent to sign)

Attending Government Official

VO Signatures
GO
APO
1)
2)
2)
3) 2)
3)
Date I z /2

From,

Vijahomkavn

To,

The Regional Passport Officer

Cochin.

Dear Sir,

Ihave changed my signature. Request you to please update the same as signed below.

Yours faithfully

Signaturee

Name Vio brabay