EMBASSYOFINDIA

(CONSULARWING)
2536MassachusettsAvenue,NW,
Washington,DC20008
Fax:(202)3876946
http://www.indianembassy.org/
APPLICATIONFORMISCELLANEOUSSERVICES

PASTEAPPLICANTSRECENT
PHOTOHERE(2"x2")

(i)
PleasesendtheoriginalvalidPassport

(ii)
PleasefilltheforminBOLDletters

(iii)
DeclarationatSectionVshouldbesignedbyIndianCitizensonly

PLEASE[X]MARKTHESERVICEAPPLIEDFOR:
[]LifeCertificate(gratis)(Mailingfee$20isrequiredwhereverapplicable)
[]POWEROFATTORNEY/AFFIDAVITSRELATINGTOPROPERTYORFINANCIALMATTERS
(Fee$20/PERATTESTATION)(Mailingfee$20isrequiredwhereverapplicable)
[]RegistrationofBirth(Fee$20/perregistration)(Mailingfee$20isrequiredwhereverapplicable)
[]ATTESTATIONOFWILL(Fee$20/perattestation)(Mailingfee$20isrequiredwherever
applicable)
[]NoObjectionCertificateforcarryingdeadbody/ashes(IndiannationalsGratis,Others$40for
carryingashes,$60forcarryingmortalremains)(Mailingfee$20isrequiredwhereverapplicable)
[]ATTESTATIONOFDOCUMENTSSUCHASPANFORM,BANKSTATEMENT,SALARYSTATEMENT,
COPYOFINDIANPASSPORT,COPYOFADOCUMENTISSUEDBYUSAUTHORITIES(USPASSPORT,
DRIVINGLICENSE,ETC.)(Fee$10/perattestation)(Mailingfee$20isrequiredwherever
applicable)
[]BirthCertificateornonAvailabilityofBirthCertificate(Fee$20/)(FillSectionIIalso)
(Mailingfee$20isrequiredwhereverapplicable)
[]AFFIDAVITFORCHILDSPASSPORTTOBEISSUEDININDIA(Fee$10/perattestation)
(Mailingfee$20isrequiredwhereverapplicable)
[]NRICertificate(Fee$20/perattestation)(Mailingfee$20isrequiredwhereverapplicable)
[]PoliceClearanceCertificate(Fee$20/or$40)(Mailingfee$20isrequiredwhereverapplicable)
[]NoObligationtoReturntoIndia(Fee$60/,$20)
(Mailingfee$20isrequiredwhereverapplicable)
[]Changeofaddress,addition/deletion&othermiscellaneousservicesonthepassport(Fee$10/)
(FillSectionIValso)(Mailingfee$20isrequiredwhereverapplicable)
[]Others(Pleasespecify)(Mailingfee$20isrequiredwhereverapplicable)
PAGE 1 OF 3

1.APPLICANTSNAMEASINPASSPORT___________________________________________________

(Surname/LastName)(MiddleName)(Given/FirstName)

2.FULLNAMEOFFATHER_________________________________________________

3.FULLNAMEOFMOTHER_________________________________________________

4.PLACE&COUNTRYOFBIRTHOFAPPLICANT_____________________________________________

5.DATEOFBIRTHOFAPPLICANT(DD/MM/YYYY)___________________________

6.NAMEANDNATIONALITYOFSPOUSE_________________________________________________

7.PERMANENTADDRESSININDIA
_____________________________________________________________________________________

_____________________________________________________________________________________

8.ADDRESSINUSA
_____________________________________________________________________________________

_______________________________________________________________

9.PROFESSION&BUSINESSADDRESS
________________________________________________________________________________

________________________________________________TEL______________________________

EMAIL_______________________________

10.CURRENTPASSPORTNO_________________________

11.PLACE&DATEOFISSUE___________________________________

12.DATEOFEXPIRY________________________________

_____________________________________________________________________________________
PLACEDATESIGNATURE

MODEOFPAYMENT:
(I)CASHIERSCHECKORMONEYORDERDRAWNINFAVOROFEMBASSYOFINDIA.
(II)CASHISACCEPTEDONLYATTHECONSULARSECTIONCOUNTER.
(III)PERSONALCHECKS/CREDITCARDSARENOTACCEPTED

PAGE 2 OF 3

SECTION II (FOR REGISTRATION OF BIRTH)

PLEASE REGISTER THE FOLLOWING CHILD/CHILDREN NAME(S) AND ISSUE BIRTH CERTIFICATE(S) TO THEM AS INDIAN
CITIZENS.
CHILDS NAME

DATE & PLACE OF BIRTH

SEX (M/F)

NOTE: The passport of both the parents and the photocopy of the Birth Certificate(s) of the above child/children should be attached. Declaration
of both parents that they have not taken any other nationality for the child / children also to be attached.
SECTION III (FOR ADDITION/DELETION OF CHILDS NAME FROM MY PASSPORT)

CHILDS NAME

DATE & PLACE OF BIRTH

SEX (M/F)

SECTION IV (FOR CHANGE OF PERMANENT ADDRESS ONLY )

OLD ADDRESS
NEW ADDRESS

SECTION V DECLARATION (TO BE SIGNED BY INDIAN CITIZENS ONLY)

I solemnly affirm that:
(i)

I owe allegiance to the sovereignty and integrity of India.

(ii)

Information given above is correct and nothing has been concealed and I am aware that it is an offence under
the Passport Act 1967 to knowingly furnish false information or suppress material information.

(iii)

I solemnly declare that I have not lost, surrendered or been deprived of my Indian Citizenship

(iv)

I further declare that I have not voluntarily acquired citizenship of any other country and I have no other
passport or travel document in my possession
(This declaration has to be notarized by a Notary Public in case of an applicant whose passport expired more
than six months before the date of the submission of this application.

Place

Date

Signature

MODE OF PAYMENT:
(I)
CASHIERS CHECK OR MONEYORDER DRAWN IN FAVOR OF EMBASSY OF
INDIA.
(II)
CASH IS ACCEPTED ONLY AT THE CONSULAR SECTION COUNTER.
(III)
PERSONAL CHECKS/ CREDIT CARDS ARE NOT ACCEPTED
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