11/3/2019 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 19-1010426965
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name SRIRAKSHA BHARATHUR SRINIVASAN
Date of Birth (DD/MM/YYYY) 15/05/1993
Validity Required NA
Place of Birth (Village/Town/City) BHADRAVATHI
District SHIVAMOGGA
State/UT KARNATAKA
Country INDIA
Gender FEMALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN FPWPS9906H
Employment Type PRIVATE
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? N
Aadhaar Number 801293910675
Family Details
Father's Name SRINIVASAN BHARATHUR NARASIMHA IYENGAR
Mother's Name BHANUMATHI BHARATHUR SRINIVASAN
Present Residential Address Details
Address KARAGODU, RAYARAKOPPAL POST, ALUR TQ, HASSAN, KARNATAKA
PIN 573129
Police Station ALUR
Mobile/Tel No. 8310534716
E-mail BSSRIRAKSHA@GMAIL.COM
Permanent Residential Address
Address KARAGODU, RAYARAKOPPAL POST, ALUR TQ, HASSAN, KARNATAKA
PIN 573129
Police Station ALUR
Mobile/Tel No. 8310534716
Emergency Contact Details
SRINIVASAN B N, KARAGODU, RAYARAKOPPAL (PO), ALUR, HASSAN
Name and Address
DIST, KARNATAK
Mobile/Tel No. 9945888141
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Aadhaar Card/e-Aadhar containing the 12 digit Aadhaar number issued by the Unique Identification Authority of India(UIDAI)
Self Declaration
I owe allegiance to the sovereignty, unity and 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 and I affirm that the information given by me in this
form and the enclosures is true and I am solely responsible for its accuracy, and 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.
Place HASSAN
Date 03/11/2019

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