10/28/2015

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FileNumber(ForOfficeUseOnly)

GOVERNMENTOFINDIA,MINISTRYOFEXTERNALAFFAIRS

PASSPORTAPPLICATIONFORM

Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/blackinkballpointpenonly.Furnishingofincorrectinformation/suppressionofinformationwouldleadtorejectionof
the application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your
originaldocumentsatthetimeofsubmissionoftheform.

ServiceRequired
ApplicationReferenceNumber

150013095924

ApplyingFor

FRESH

TypeofApplication

NORMAL

TypeofPassportBooklet

NORMAL

ApplicantDetails
Applicant'sName

PRATIKRAMDASMALOKAR

DateofBirth(DD/MM/YYYY)

22/06/1994

PlaceofBirth(Village/Town/City)

WARDHA

District

WARDHA

State/UT

MAHARASHTRA

Country

INDIA

Gender

MALE

MaritalStatus

SINGLE

CitizenshipofIndiaby

BIRTH

PAN

CTCPM1724Q

EmploymentType

NOTEMPLOYED

Iseitherofyourparent(incaseof
minor)/spouse,agovernmentservant?

EducationalQualification

10THPASSANDABOVE

Signature/LeftHandThumbImpression
ofIlliterateApplicantandMinorswho
cannotsign.

AreyoueligibleforNonECRcategory? N
VisibleDistinguishingMark

NO

FamilyDetails
Father'sName

RAMDASAMBADASMALOKAR

Mother'sName

DHANSHRIMALOKAR

PresentResidentialAddressDetails
ResidingSince(MM/YYYY)

01/2001

Address

NEWMHADACOLONYQ.NOL17ARVIROADWARDHA,
WARDHA,WARDHA,WARDHA,MAHARASHTRA

PIN

442001

Mobile/TelNo.

9960528503

https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=150013095924

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10/28/2015

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Email

PRATIKMALOKAR1@GMAIL.COM

FirstReferenceNameAndAddress

PALASHKSHIRSAGARNEWMHADACOLONYQ.NOL21
ARVIROADWARDHA

Mobile/TelNo.

8657558620

SecondReferenceNameAndAddress

NIDHIGOMASENEWMHADACOLONYARVIROAD
WARDHA

Mobile/TelNo.

8378064956

PermanentResidentialAddress
Address

NEWMHADACOLONYQ.NOL17ARVIROADWARDHA,
WARDHA,WARDHA,WARDHA,MAHARASHTRA

PIN

442001

Mobile/TelNo.

9960528503

EmergencyContactDetails
NameandAddress

PRATIKRAMDASMALOKARNEWMHADACOLONYQ.NOL
17ARVIROADWARDHA

Mobile/TelNo.

9960528503

Email

PRATIKMALOKAR1@GMAIL.COM

PaymentDetails
ModeofPayment

Challan

Date

26/10/2015

Receipt/ReferenceNo.

9809390

AmountReceived(Rs.)

1500.00(ONETHOUSANDFIVEHUNDREDONLY)

Enclosures
1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

SelfDeclaration
Ioweallegiancetothesovereignty,unityandintegrityofIndia,andhavenotvoluntarilyacquiredcitizenshiportraveldocument
ofanyothercountry.Ihavenotlost,surrenderedorbeendeprivedofthecitizenshipofIndiaandIaffirmthattheinformationgiven
bymeinthisformandtheenclosuresistrueandIamsolelyresponsibleforitsaccuracy,andIamliabletobepenalizedor
prosecuted if found otherwise. I am aware that under the Passports Act, 1967 it is a criminal offence to furnish any false
informationortosuppressanymaterialinformationwithaviewtoobtainingpassportortraveldocument.

Place

WARDHA

Date

23/10/2015

Signature/LeftHandThumbImpressionof
Applicant(Ifapplicantisminor,either
parenttosign)

https://portal1.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=150013095924

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