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FileNumber(ForOfficeUseOnly)

GOVERNMENTOFINDIA,MINISTRYOFEXTERNALAFFAIRS

PASSPORTAPPLICATIONFORM

Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/blackinkballpointpenonly.Furnishingofincorrectinformation/suppressionofinformationwouldleadtorejectionof
the application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your
originaldocumentsatthetimeofsubmissionoftheform.

ServiceRequired
ApplicationReferenceNumber

161007136033

ApplyingFor

FRESH

TypeofApplication

NORMAL

TypeofPassportBooklet

NORMAL

ApplicantDetails
Applicant'sName

UMARSYED

DateofBirth(DD/MM/YYYY)

30/06/1987

ValidityRequired

NA

PlaceofBirth(Village/Town/City)

HYDERABAD

District

RANGAREDDY

State/UT

TELANGANA

Country

INDIA

Gender

MALE

MaritalStatus

MARRIED

CitizenshipofIndiaby

BIRTH

PAN

BPKPS2346D

VoterId

ZTS2839902

EmploymentType

PRIVATE

Iseitherofyourparent(incaseof
minor)/spouse,agovernmentservant?

EducationalQualification

10THPASSANDABOVE

Signature/LeftHandThumbImpression
ofIlliterateApplicantandMinorswho
cannotsign.

AreyoueligibleforNonECRcategory? Y
AadhaarNumber

474176605184

FamilyDetails
Father'sName

YOUSUFSYED

Mother'sName

SADHAKABEGUMSYED

Spouse'sName

ARSHIYASULTANASYED

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PresentResidentialAddressDetails
ResidingSince(MM/YYYY)

06/1987

Address

47155ANANDCOLONYHAYATHNAGAR,HYDERABAD,
HAYATHNAGAR,CYBERABAD,TELANGANA

PIN

501505

Mobile/TelNo.

9542119798/04032985003

Email

SYEDUMAR.QC@GMAIL.COM

FirstReferenceNameAndAddress

MD.MAJEED,47153,ANANDCOLONY,HAYATHNAGAR,
RANGAREDDYDIST,501505.

Mobile/TelNo.

9395549322

SecondReferenceNameAndAddress

SYEDGOUSE,47155,ANANDCOLONY,HAYATHNAGAR,
RANGAREDDYDIST,501505

Mobile/TelNo.

9030055572

PermanentResidentialAddress
Address

47155ANANDCOLONYHAYATHNAGAR,HYDERABAD,
HAYATHNAGAR,CYBERABAD,TELANGANA

PIN

501505

Mobile/TelNo.

9542119798/04032985003

EmergencyContactDetails
NameandAddress

SYEDYOUSUF47155,ANANADCOLONY,HAYATHNAGAR,
RANGAREDDYDIST,501505

Mobile/TelNo.

9391330053/04032985003

FeeDetails(NottobefilledbyapplicantssubmittingtheapplicationatPassportSevaKendra/PassportOffice)
Feeamountin(Rs)

IfpaidbyDemandDraft(DD),providethefollowingdetails
DDIssueDate(dd/mm/yyyy)

DDExpiryDate(dd/mm/yyyy)

BankName

Branch

Enclosures
1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

SelfDeclaration
Ioweallegiancetothesovereignty,unityandintegrityofIndia,andhavenotvoluntarilyacquiredcitizenshiportraveldocument
ofanyothercountry.Ihavenotlost,surrenderedorbeendeprivedofthecitizenshipofIndiaandIaffirmthattheinformationgiven
bymeinthisformandtheenclosuresistrueandIamsolelyresponsibleforitsaccuracy,andIamliabletobepenalizedor
prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false
informationortosuppressanymaterialinformationwithaviewtoobtainingpassportortraveldocument.

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Place

HYDERABAD

Date

09/08/2016

Signature/LeftHandThumbImpressionof
Applicant(Ifapplicantisminor,either
parenttosign)

Print

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