11/19/24, 7:44 AM 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 24-1014070319
Applying For REISSUE
VALIDITY EXPIRED WITHIN 3
YEARS/DUE TO EXPIRE. , CHANGE
If Re-issue, specify reason(s)
IN EXISTING PERSONAL
PARTICULARS
If change in existing personal
ADDRESS
particulars, specify
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name GOPAL GANDI
Date of Birth (DD/MM/YYYY) 02/02/1980
Validity Required NA Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
Place of Birth (Village/Town/City) SURYAPET cannot sign.
District SURYAPET
State/UT TELANGANA
Region/Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type PRIVATE
Is either of your parent (in case of
N
minor)/spouse, a government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? Y
Aadhaar Number 643237892895
Family Details
Father's Name PULLAIAH GANDI
Mother's Name SATYAMMA GANDI
Spouse's Name PREMALATHA GANDI
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Present Residential Address Details
153 ROAD NO 5 SYNERGY HOMES, TURKAYAMJAL,
Address
RACHAKONDA-RANGAREDDY, TELANGANA
PIN 501510
Police Station ADIBATLA
Mobile/Tel No. 9989515738
E-mail GANDIGOPAL@[Link]
Permanent Residential Address
153 ROAD NO 5 SYNERGY HOMES, TURKAYAMJAL,
Address
RACHAKONDA-RANGAREDDY, TELANGANA
PIN 501510
Police Station ADIBATLA
Mobile/Tel No. 9989515738
Emergency Contact Details
Name and Address PREMALATHA
Mobile/Tel No. 9704629959
Previous Passport
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number M3963777
Date of Issue 04/12/2014
Date of Expiry 03/12/2024
Place of Issue HYDERRABAD
File Number HY2077855267714
Other Details
Payment Details
Mode of Payment UPI
Date 19/11/2024
Receipt/Reference No. CPAELXFRZ7
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED ONLY)
Enclosures
[Link] Card issued by the Income Tax Department
[Link] Card (Address Proof)
[Link] stating how and where the Passport got lost/ damaged as per Annexure F
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.
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Place HYDERABAD Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
Date 19/11/2024 to sign)
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