7/21/25, 10:08 PM ViewPrintApplicationReceipt
File Number (For Office Use Only)
Ministry of External Affairs, Government of India
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 - 25-1057207784 Please paste your
Number unsigned recent
Applying For - FRESH color photograph
of size 4.5cm *
Type of Application - NORMAL 3.5cm.
Type of Passport - NORMAL
Booklet
Applicant Details
Applicant's Name - SANIYAJ SK
Date of Birth - 18/04/2003
(DD/MM/YYYY) Signature/Left Hand Thumb
Validity Required - NA Impression of Illiterate Applicant and
Minors who cannot sign.
Place Of Birth - PUJALI
(Village/Town/City)
District - DIAMOND HARBOUR
State/UT - WEST BENGAL
Region/Country - INDIA
Gender - MALE
Marital Status - SINGLE
Citizenship of India by - BIRTH
PAN - NFQPS2242L
Voter ID - AIV2366532
Employment Type - OTHERS
Is either of your parent - N
(in case of
minor)/spouse, a
government servant?
Educational - BETWEEN 8TH AND 9TH STANDARD
Qualification
Are you eligible for - N
Non-ECR category
Aadhaar Number - 412402770706
Family Details
Father Name - SK KUTUBUDDIN
Mother Name - SAHANARA BEGAM
Present Residential Address Details:
Address - 8/1, MASJIDTALA PARA, PUJALI, DIAMOND HARBOUR, WEST BENGAL
Pin - 700138
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7/21/25, 10:08 PM ViewPrintApplicationReceipt
Police Station - BUDGE BUDGE
Mobile/Tel No - 9163834069
Email - SANIYAJS9@[Link]
Permanent Residential Address Details
Address - 8/1, MASJIDTALA PARA, PUJALI, DIAMOND HARBOUR, WEST BENGAL
Pin - 700138
Police Station - BUDGE BUDGE
Mobile/Tel No - 9163834069
EmergencyContactDetails:
Name and Address - SK RIYAJUL, MASJIT TALA 1M LEN,PASCHIM PUJALI,BUDGE BUDGE ,KOLKATA-
700138
Mobile/Tel No. - 7044525064
Previous Passport
Other Details
Fee Details (Not to be filled by applicants submitting the application at Passport Seva
Kendra/Passport Office)
Fee amount in (Rs) -
If paid by Demand Draft(DD), provide the following details
DD Issue Date (dd/mm/yyyy) -
DD Expiry Date (dd/mm/yyyy) -
Bank Name -
Branch -
Enclosures:
1. Electors Photo Identity Card (EPIC)2. Birth certificate issued by the Registrar of Births and Deaths or the Municipal
Corporation or any other authority, empowered under the Registration of Births and Deaths Act, 1969 (18 of 1969)
Self Declaration
I owe allegiance to the sovereignty, unity & 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. I have not
contravened any of the conditions relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am not
suppressing any material information in this regard. I further affirm that the enclosures and documentary proof submitted
in support of my application for an Indian passport are authentic and solely pertain to me and I am fully responsible for
the accuracy of the same. 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.
I have read and understood the contents of the above and by submitting this form certify that all the information
submitted by me in the form is bonafide.
Place - PUJALI
Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either
Date - 21/07/2025
parent to sign)
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