4/19/2018 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External

Affairs

Service Required
Application Reference Number 18-1003900181
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet JUMBO
Applicant Details
Applicant's Name BASAVARAJ PUTTASWAMY
Date of Birth (DD/MM/YYYY) 04/07/1987
Validity Required NA
Place of Birth (Village/Town/City) BHADRAVATHI
District SHIVAMOGGA
State/UT KARNATAKA
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN ASKPB4174G
Voter Id INA8830861
Employment Type GOVERNMENT
Organisation name KARNATAKA POWER TRANSMISSION CORP LT
Is either of your parent (in case
of minor)/spouse, a government N
servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR
Y
category?
Visible Distinguishing Mark NO
Aadhaar Number 473572807751
Family Details
Father's Name PUTTASWAMY NANJUNDASHETTY
Mother's Name JAYALAKSHMI
Spouse's Name USHA BASAVARAJ
Present Residential Address Details
Residing Since(MM/YYYY) 05/2017
32,SRI LAKSHMI VENKATESHWARA NILAYA,BALAJI LYT,
Address HEGGADADEVANAPURA, DASANAPURA(H), MADANAYAKANAHALLI,
BENGALURU RURAL, KARNATAKA
PIN 562123
Mobile/Tel No. 9844013811
E-mail BASAVARAJBDVT@GMAIL.COM
Previous Residence Details
Previous Residence1
Residing Since From(MM/YYYY) 01/2016
Residing Since To(MM/YYYY) 04/2017
750,C/O SHANTHAKUMAR,ALUR THAPOVANA,ALUR, ALURU,
Address
MADANAYAKANAHALLI, BENGALURU RURAL, KARNATAKA, INDIA

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4/19/2018 Application Form

PIN 562123
Emergency Contact Details
Name and Address MAHESH
Mobile/Tel No. 9900000087
Mobile/Tel No. 9900000087
Other Details
Enclosures
1.Driving License issued by the Transport department of concerned state Government
2.Aadhaar Card
3.No Objection Certificate (NOC) as per Annexure G
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 BENGALURU
Date 19/04/2018
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