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 22-1009792817
Applying For REISSUE
VALIDITY EXPIRED WITHIN 3
If Re-issue, specify reason(s)
YEARS/DUE TO EXPIRE.
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name JITHIN NARAYANAN
Date of Birth (DD/MM/YYYY) 21/03/1989
Validity Required NA
Place of Birth (Village/Town/City) KOLENCHERY
District ERNAKULAM RURAL
State/UT KERALA Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors
who
Region/Country INDIA cannot sign.
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN BDQPN3114C
Voter Id IAD0248039
Employment Type PRIVATE
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? Y
Visible Distinguishing Mark BLACK MOLE ON THE LEFT UPPER LIP
Aadhaar Number 618022463935
Family Details
Father's Name NARAYANAN CHALIL KUNJAPOO
Mother's Name GEETHA NARAYANAN
Present Residential Address Details
Address CHALIL HOUSE,KUMBALATHUMURI, NADUKANI P O,
KOTHAMANGALAM, ERNAKULAM RURAL, KERALA
PIN 686691
Police Station KOTHAMANGALAM
Mobile/Tel No. 7012769748 / 9744274340
E-mail JITHIN70127@[Link]
Permanent Residential Address
CHALIL HOUSE,KUMBALATHUMURI, NADUKANI P O,
Address
KOTHAMANGALAM, ERNAKULAM RURAL, KERALA
PIN 686691
Police Station KOTHAMANGALAM
Mobile/Tel No. 7012769748 / 9744274340
Emergency Contact Details
Name and Address NARAYANAN
Mobile/Tel No. 9744274340 / 7012769748
E-mail JITHINNARAYANANCHALIL123@[Link]
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number K0396383
Date of Issue 18/04/2012
Date of Expiry 17/04/2022
Place of Issue COCHIN
File Number COCB00003812
Other Details
Payment Details
Mode of Payment Debit/Credit Card
Date 26/08/2022
Receipt/Reference No. CPABZMUAU8
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
[Link] Card/E-Aadhaar
[Link] Card (Address Proof)
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.
Signature/Left Hand Thumb Impression of
Place KOTHAMANGALAM
Applicant
(If applicant is minor, either parent
to sign)
Date 26/08/2022
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