3/25/2019 View/Print Submitted Form

File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS

PASSPORT APPLICATION FORM

Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of the
application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original
documents at the time of submission of the form.

Service Required
Application Reference Number 18-0019028832

Applying For FRESH

Type of Application NORMAL

Type of Passport Booklet NORMAL

Applicant Details
Applicant's Name FARZANA BEGUM

Date of Birth (DD/MM/YYYY) 01/01/1973

Validity Required NA

Place of Birth (Village/Town/City) ETAWAH

District ETAWAH

State/UT UTTAR PRADESH

Country INDIA
Signature/Left Hand Thumb Impression
Gender FEMALE of Illiterate Applicant and Minors who
Marital Status MARRIED cannot sign.

Citizenship of India by BIRTH

PAN DEAPB5663H

Employment Type HOME MAKER

Is either of your parent (in case of

N
minor)/spouse, a government servant?

Educational Qualification BETWEEN 8TH AND 9TH STANDARD

Are you eligible for Non-ECR category? N

Aadhaar Number 976993722441

Family Details
Father's Name AZIZ KHAN

Mother's Name FAHMEEDA BEGUM

Spouse's Name MUSHARRAF HUSAIN

Present Residential Address Details

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3/25/2019 View/Print Submitted Form
Address E-123, 4TH FLOOR, FATIMA APPT,SHAHEEN BAGH AFE-2,
OKHLA, JAMIA NAGAR, SOUTH EAST DELHI, DELHI

PIN 110025

Mobile/Tel No. 9891791057 / 9891066577

E-mail AFREENHUSAIN0@GMAIL.COM
Permanent Residential Address
E-123, 4TH FLOOR, FATIMA APPT,SHAHEEN BAGH AFE-2,
Address
OKHLA, JAMIA NAGAR, SOUTH EAST DELHI, DELHI

PIN 110025

Mobile/Tel No. 9891791057 / 9891066577

Emergency Contact Details
Name and Address ASHRAF HUSAIN, E-123 TOP FLOOR FATIMA APARTMENT

Mobile/Tel No. 9911343278

E-mail ASHRAFHUSAIN00@GMAIL.COM
Payment Details
Mode of Payment Online/Internet Banking

Date 17/03/2019

Receipt/Reference No. CPO7780119

Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)

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 NEW DELHI Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 23/12/2018 to sign)

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