HIGH COMMISSION OF INDIA

HIGH COMMISSION OF INDIA,WISMA HRIH LOTUS,LEVEL 1,442,JALAN

PAHANG,SETAPAK,53000,KUALA LUMPUR,MALAYSIA
00-603-62052350, http://www.indianhighcommission.com.my/
APPLICATION FORM FOR INDIAN PASSPORT
Generated On: 7/10/2021, 2:04:54 PM
PASSPORT PREVIEW

भारत गणराज्य REPUBLIC OF INDIA

टाइप/Type राष्ट्र कोड/CountryCode पासपोर्ट नं./PassportNo.

Paste your P IND

unsigned recent उपनाम/Surname

color photograph MUNIYANDI

Size 2"X2" and दिया गया नाम/Given Name(s)

Signature/Left KATTU RAJA

Hand Thumb राष्ट्रीयता/Nationality लिंग/Sex जन्मतिथि/Date of Birth

Impression in the INDIAN M 03/05/1976

box provided below जन्म स्थान/Place of Birth

MUTHUPET, TAMIL NADU

जारी करने का स्थान/Place of Issue

जारी करने की तिथि/Date of Issue समाप्ति की तिथि/Date of Expiry

पिता/कानूनी अभिभावक का नाम/Name of Father/Legal Guardian

MUNIYANDI
माता का नाम/Name of Mother

NAYAGAM
पति या पत्नी का नाम/Name of Spouse

BAKYA LAKSHMI
पता/Address

4/24 NEW KALIYAMMAN KOVIL STREET

MUTHUPET, THIRUVARUR
PIN:610004, TAMIL NADU, INDIA
पुराने पासपोर्ट का नं. और इसके जारी होने की तिथि एवं स्थान/Old Passport No with Date and Place of Issue

K0855342 25/04/2012 KUALA LUMPUR

फ़ाइल नं./File No.

Note: Please paste your unsigned recent color photograph Size 2"X2" and Signature/Left Hand Thumb Impression in the box provided above.

SERVICE REQUIRED
Application Reference Number 21-2002454376
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
If change in existing personal particulars, specify
If other, specify
Type of Application TATKAAL
Type of Passport Booklet 36 Pages
APPLICANT DETAILS
Applicant's Name KATTU RAJA MUNIYANDI
Applicant's Alias Name N
Alias Name1
Alias Name2
Applicant's Change In Name N
Previous Name1
Previous Name2
Date of Birth (DD/MM/YYYY) 03/05/1976
Validity Required NA
Place of Birth (Village/Town/City) MUTHUPET
District SIVAGANGA
State/UT TAMIL NADU
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN
Voter Id
Employment Type PRIVATE
Organisation name
Is either of your parent (in case of minor)/spouse, a government servant? N
Educational Qualification BETWEEN 8TH AND 9TH STANDARD
Are you eligible for Non-ECR category? N
Visible Distinguishing Mark
Aadhaar Number

FAMILY DETAILS
Father's Name MUNIYANDI
Mother's Name NAYAGAM
Legal Guardian's Name
Spouse's Name BAKYA LAKSHMI
Father's Passport No
Father's Nationality
Mother's Passport No
Mothers's Nationality
PASSPORT PRINTABLE ADDRESS DETAILS
4/24 NEW KALIYAMMAN KOVIL STREET
To be printed on passport MUTHUPET, THIRUVARUR
PIN:610004, TAMIL NADU, INDIA
Mobile/Tel No. 60175682285 / 0175682285
E-mail SYARIKATBERSAUDARA57@GMAIL.COM
OTHER ADDRESS DETAILS
17 JALAN LANGKAWI
Address GEORGETOWN
10460, MALAYSIA
Mobile/Tel No. 60175682285
EMERGENCY CONTACT DETAILS
Name and Address MOHD MUDZILL
Mobile/Tel No. 60175682285 / 0175682285
E-mail MUDZILL@YAHOO.COM
PREVIOUS PASSPORT
DETAILS OF LATEST HELD/EXISTING/LOST/DAMAGED
Y
ORDINARY PASSPORT/ IDENTITY CERTIFICATE
Passport Number K0855342
Date of Issue 25/04/2012
Date of Expiry 24/04/2022
Place of Issue KUALA LUMPUR
File Number MYSD01045212
HAVE YOU EVER APPLIED FOR PASSPORT, BUT NOT
N
ISSUED?
File Number
Date of Issue
Name of passport office where applied
DETAILS OF PREVIOUS/CURRENT DIPLOMATIC/OFFICIAL
N
PASSPORT
Passport Number
Date of Issue
Date of Expiry
Place of Issue
1) Provide the following details if there are any criminal proceedings pending
against the applicant.
1.1) Are any proceedings in respect of an offence alleged to have been
N
committed by you pending before a criminal court in India?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.2) Has any warrant or summons for your appearance been issued and
N
pending before a court under any law for the time being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.3) Has a warrant for your arrest been issued by a court under any law for
N
the time being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.4) Has an order prohibiting your departure from India been made by any
N
court?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
2) Provide the following details if the applicant has been convicted by a court
in India.
2.1) Have you at any time during the period of five years immediately
preceding the date of this application been convicted by a court in India for
N
any offence involving moral turpitude and sentenced in respect thereof to
imprisonment for not less than two years?
Court Name and Place
Case/FIR/Warrant Number
Date of Conviction
3) Provide the following details if the applicant has been refused/denied
passport.
3.1) Have you ever been refused/denied passport? N
Reason for refusal or denial of passport
3.2) Has your passport ever been impounded? N
Passport Number
Reason for impounding/revocation
3.3) Has your passport ever been revoked? N
Passport Number
Reason for revocation
4) Provide the following details if applicant has applied for or been granted
foreign citizenship.
4.1) Have you ever applied for or been granted citizenship by any other
N
country?
Name of the country
4.2) Have you ever held the passport of any other country at any time? N
Name of the country
4.3) Have you ever surrendered your Indian passport? N
Surrendered Indian passport number:
4.4) Have you ever applied for renunciation of Indian citizenship? N
Application Details:
Name of place where application submitted:
5) Provide the following details if applicant has returned to India on
Emergency Certificate.
5.1) Have you ever returned to India on Emergency Certificate (EC)? N
EC No.
Date of Issue
Issuing Authority
Country from where travelled on EC/deported/repatriated
Date of Return to India
Reason for issuing EC/deported/ repatriated
5.2) Have you ever been deported from any country? N
If yes, was the cost borne by the Government of India and if so, has the same
been refunded?
5.3) Have you ever been repatriated from any country back to India? N
If yes, was the cost borne by the Government of India and if so, has the same
been refunded?
SELF DECLARATION
I declare:

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.

I understand:

That Ministry of External Affairs (MEA) (or its implementation partner agencies/stakeholders/third parties) may undertake required checks to

confirm the accuracy and authenticity of evidence I have provided and documents I have submitted with this application.
That the information I provide, including biometric data (if any), will be treated in confidence, but it may be disclosed to other government

departments, agencies, local authorities, foreign governments, and other implementation partner agencies/stakeholders/third parties to enable
MEA or those bodies to perform their duties.

That providing biometric information, if collected as part of an application, is confirmation of my consent to getting the biometric information

checked to verify identity.

That the Passport and related services applications may be handled by the Indian Embassies/Consulates/ Passport Office/other offices

including outside of the country in which I have applied and that this may involve the transfer of my application and supporting documents to
and from the respective offices.

That my details may, in certain circumstances, be passed to Police, Intelligence and other Fraud Detection & Prevention agencies. I also

understand that such agencies may provide related information about me to MEA.

PENANG
Place Signature/Left Hand Thumb Impression of Applicant
MALAYSIA
(If applicant is minor, either parent to sign)
Date 10/07/2021