"ret a coe roe (NACH CouterNo: A25 (0970172023 Mon 09:31:26 CSE: PsP2tz80 ARN : 22-0020490526 PASSPORT APPLICATION FORM Government of INDIA, Ministry of External Affairs Srence! Let Hand Thunb impression otApptcent Ssh 2 (worm be cestrated bx oy) os Sy L 4 UTTAR PRADESH, INDIA Gender FEMALE Martal Situs: ‘SINGLE — Cezenstip ot sa By BRTH PAN AFNPOREEIK Emeioyment Type STUDENT va 's ether of your perent{f minoryspouse.2 govemment servant? N Eeucaton Quattcaton (GRADUATE AND ABOVE Eigble ter Non ECR eategoy? —-¥ Aachaar Number 847225432080 Family Details “a Feners Neve YOSESH GUPTA Meters Name Mansy GUPTA Present Residential Address Details Accress ‘MOHALLA CHOWK SHAHABAD DEHATHARDO! PIN:241124,UTTAR PRADESH,INDIA Petes Steen SHAHABAD Mcbile/Telephone Number 7905007338/ 9936488845, oe EneiD umnatomart23¢gnalleom Permanent Residential Address Detals Aecress MOHALLA CHOWK, SHAHABAD DEHAT, HARDOI, SHAHABAD, UTTAR PRADESH PN e128 MobieTTeleptone Number Tsosco7a3e/ sex6488845 Emergency Contact Detalls Name and Acres ‘YOGESH KUMAR GUPTA, 2 CHOWK SHAHABAD HARDOI Mobile elephone Number 2299037925 ]ARN : 22-0020490526 Confdentiah -Page 2of 2- (09701/2023 Mon 09:31:26 Have you ever applied for passport. but not issued? N Enclosure List Declarations POB- PAN CARD; POA- AADHAAR CARD: Other Details Self Declaration Two allegiance tothe sovereignty. unt &Integrty of Inda, and have not voluntary acquired cizenship or travel document of ay other country, | have not lost, surrendered or been deprived ofthe ckizenship of India. | have not contravened any ofthe condlions relating to the possession and use of an indian passport | efi thatthe information end particulars gWven by me inthis form are true end correct. I further state that! am not suppressing ny tmatepel information in this regard. further arm that the enclosures and documentary proof submited in support of my application for an thdich passport are euthente and solely pertain to me and | am fuly responsible for the accuracy ofthe same. | am lable tobe Penalznd or prosecuted If found otherwise. | am avare tht under the Passports Act, 1967 Isa criminal offence to furs any fale Infomation of to suppress any matetal information wth a view to obtalning passport or travel document. nave read and understood the contents ofthe above and by submiting this frm cert tha lhe information submited by me inthe form Is bonafice. | hereby conti that all documents Including original and photocopies thereot have been hended over back to me Po requited documents. Furthermore, | solemnly afi that: | have not been charged wth criminal proceedings nor is there any arrest warrant or summon p against me. * During the 5 years immediately preceding the date of this application, | have not been convicted by any criminal offence and sentenced to Imprisonment for two years or more. {have nelther refused of denied passport nor my passport has been impounded or revoked. * Lave never applied for, nor was | ever granted poltical asylum by any forelgn country. + {have never retuned to India on Emergency Cartficate nor was | ever deported or repatriated to India. st aigitization of ending before any Court of Law in india Court of Law In india for any Place SHAHABAD Signature Len Hand Thum : 7 src tpt Be outs onovn0zs Teoemeane A) parento sign) ri 7 Attending Government Official Signatures vo GO APO 0 0 0, a, a, 2 a. 2 3.me iy pypeo ome TCT € DEEP" GOVERNMENTOF DTA aE ate Unnati Ofrar ‘ars Fairy DOB: 18/10/2000 nffer / FEMALE 8472 2643 2090 are, Saar ae sitter spare ae, eT ee, ere i arm, ere, se weer 241124 8472 2643 2090 IERA AADHAAR MERI PEHACHANmB xu del/ S.No.SSE/2016 Centra! Board of Secondary E 7 Registration he: « esti fererera ita (a 3 us15/08¢67/0091 SECONDARY SCHOOL EXAMINATION (SESSION 12014. 16) ig vite Ae POUT TTT UR Grade Sheet cum Certificate of Pertormance 4% This is to Certity that emp pou Not Uebel UNNATI OMAR But Rolo. 54 pea MANJU GUPTA I YOGESH GUPTA 18/10/2000 18TH OCTOBER TWO THOUSAND uy 98867-MANAS STHALI N H 24 NEAR FARIDPUR BAREILLY UP b- has performed as follow’ ne ‘Subject Code and Name 401 ENGLISH COMM. (002 HINDI COURSE A 041, MATHEMATICS 086 SCIENCE 087 SOCIAL SCIENCE Easily identifies personal strengths and weaknesses and uses them to arrv 2 (8) 774 fren work Edueation : arta Work Eaveation effectively and constructively, handles stress well, appropriately and readily takes help when needed. T Innovative, with excellent grasp of any assignment, very punctual in the | of any assignment and is very punctual in| Completion of any assigned task, self-motivated, empathetic, inspires others an; tivated, empathetic, inspires others and, an excellent team worker, ly shoulders respor “21IC) Fe sit Hea WH Visual ans Pertorming Arts : apales actively in artistic activites at conducts creatv events onsen innovative approach tothe appecaaen omer = AUMTeE THA Deseript Ourteous to teachers and elders, has a positive ing and adheres to school and class norms, eso teachers and takes feedback and attitude towards learning, communi in teachers, accepts feedback and cr | Sensitive and supportive towards peers and | A | expresses ideas and oj opinions and sugge ly-abled schoolmates, tonew | Enthusiastic, shoulders responsi School programmes, possesses. ‘about the environment. Partici | Punctual and takes part in schoo! programmes regula sdership qualities and displays team spirit, motivates and inspires others {0 participate. Respects school property and takes pride In the school, Understands value systems, abides by rules and reg) courteous towards peers and elders, resp sensitive to diversity and shows empathy | Abides by rulos and undorstands valuo systems. Honest, courteous toward A | peers and eld | and symbols, sens urea adeaTd Co- Curricular Ad tively plans and participates in lterary and crea ary and erative events at Actively plane and navtlcte af ism and composes poems, | a soni Value Systems AREFATY Co- Curnicular Aet creative writing, dectamation et Jan avid reader, creative and collaborates eas! Possesses good organi gee SATE Upgraded Grado ; 1. Bs, CHAUHAN rineipal . soon cx er far) Dethi oon ie for pt ee cation from the website rammeasocmie 1c ad downoad teas 2p abe Tu Te.tntaly validate he coricate please visit cbse.nc na or oars svi NSIS RN TST REREAD A ROE