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Gorernnrent of llladh1'a Pradesh, '
Honre(Passport) Department,
Nila n tralaya, Bhopa l(M.P.)
-- -'-FORil{ FOR ATITHENI'ICATION OF ORIGINAL DOCUMENTS
NOTE -(1) This form should be filled in Capital Letters only.
(2) Please read the jnslructions carefully before filling up form.
-'_--- -.---.(3.)$nrnishing *rong i4formation or fake documents for authentication is
, punishable offence
AFFIX SELF
--Ta, A]*IESTED
I he Secr etary, PASSPORT SIZE
Go'"t. olMadhya Pradesh, PHOTOGRAPH
Home Departmeni.
lr{antralaya,
'Bhopal--N{.P.
PART-I
Ir.l Nane the Applicant
tt (r\r 'rf I
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tt ;r,sr Educatiotrai Docunrcl'.s l
Sumanre Name h.f idrile name
I 2 lvlale Fernale I
3. Nationali
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Birih olthe Apol i.':r:t
DD lvil\j YYYY
Fiisiso!"t Details'
l'ass ri )llrrt: h -'r D;ti: i:1 \.,'eit<.1ii
6 Father's I'iame I
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Jr'lother's Narrie I
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.-+-_',1
ilresent Address
House No. i R<.,ad
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.Sirt,'
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PIN Cod.: I I ariiiine hl,,l, r:,
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l)e rnra n err t R-esidc:ntiai r\ rlr.i ress i
I iouse )io Itcad !
-ieirsii
N{ohalia I
qr ri-
D!s:rr*
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Pli.j Code i.li:dli;re onii:
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l0 Details of Present Employment
Name of Employer and Address
Building Road
Locality j City
District State
-PIN Code Land Line No. Mobile No.
for authentication
ustne tc
Destination (Country)
tion of Visit
t2 etails of the original docunrents sought to be authenticated-
st. Name of Documents Date of Issue Name of Issuing Designation of the
Nd.
Authori[, Issuing authoritv with
Address
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tTul
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l Details f copies of I)ocuments enclosed
<.r
Pll rnose Nos Details of docu rnents
a Passport ]I
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.b Residential Proof I
c Documents to be attested 2
d Offer letter etc. -,--l
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e _A.ffid-ayi(Original) I
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Signature of Applicant rvith date
Name in full (ln Block letters)
PAP.T II
(For pcrsons pra;enting form or bchalfof the applicrnt)
l4 Name
l5 Father's Name
l6 Reiationship rvith appl icanr
l7 Passport Passport Number issu in ,(r L, Date of Va itv
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t8 Residential Address
tr
House }..to. R oad
Moha lla Tch 5r
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Distribr I
State
PIN Code
Land Line No Mobile Ni
.1
l9 Occupation and Office
Addrtss I
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Underiaking to be furrisir&l the Applicani for authorti
I)-y other
persons lo gei documents authenticated
authorize ShriiSmt. ----------S/D/W o
:----:*-_---R/o- _---____-__
:--*
to proCrce the oo:urnents rnentioneC in panJ, Seriat no. I I for autlren; i ton.
Three sa:rples lfsignature ofthe authorized person are certtticd by mc as fo I
( r )-------------
(2)
(l)-
Signature ol Applicant wr r ale
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PART.III
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UNDf,RT.AKING T(
BE FURNISHED BY THE APPLICANT AND BY
PERSONS PRESEN' 'ING FORM ON BHHALF OF THE APPLICANT.
:
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DECLARATIoN
i
I solemnly declare lhat the documenls prescnted for autirentication'is/are
f
original and the informal:on given by me in this fom are true to the best of my
k;o;;e .lsc. ouj i-,"i;cf. lf ,re docrrmehts submitteci by ine are founC to be fake or
interpolated or the inforn. ii'on fumished by me are.forurd lo be false, then I shall
be liable to b€ piosecuted.
Trr be signed by the Appliu ni/
.u
Signature of applicant
Authorized Person on ;"cel t
Y Name in fi.rll (ln Bloc l- ro.ct s)
ol-original authehlicated D, :ument /
