4/22/2019 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 19-0005589346
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name MAYANK NAGPAL
Date of Birth (DD/MM/YYYY) 05/03/2000
Validity Required NA
Place of Birth (Village/Town/City) GWALIOR
District GWALIOR
State/UT MADHYA PRADESH
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
Employment Type STUDENT
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 862235016458
Family Details
Father's Name AJEET NAGPAL
Mother's Name SANDHYA NAGPAL
Present Residential Address Details
COMPANY BAGHROAD, MURRAR,GIRD,GWALIOR, GWALIOR, MORAR,
Address
GWALIOR, MADHYA PRADESH
PIN 474006
Mobile/Tel No. 8770559455
E-mail NAGPALMOHIT53@GMAIL.COM
Permanent Residential Address
COMPANY BAGHROAD, MURRAR,GIRD,GWALIOR, GWALIOR, MORAR,
Address
GWALIOR, MADHYA PRADESH
PIN 474006
Mobile/Tel No. 8770559455
Emergency Contact Details
Name and Address MAYANK NAGPAL
Mobile/Tel No. 8719083784
E-mail NAGPALMOHIT53@GMAIL.COM
Other Details
Enclosures
1.Transfer/School leaving/Matriculation Certificate issued by the school last attended/recognised educational board
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 GWALIOR
Date 22/04/2019

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