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IMMIHELP.COM POLAROID/INSTANT PHOTOS NOT

ACCEPTABLE

SL.No. EAPX- 1 -04

From No I External
GOVERNMENT OF INDIA
(APPLICATION FORM FOR INDIAN PASSPORT AT AN INDIAN MISSTON/POST)

(for the issue ofan ordinary international passport Paste your unsigned
Fresh / After l0 years (final) / and for duplicate recent colour
in lieu of lost / damaged passport photograph.
Size:2" X2"

Specimen Signature
tsokdF.
Payment of Fee (to be filled py gpplicant)
Amount paid $/E ........*. 3:.5.'..:.............. by..€.RJ.H.!.€8.....f.i1f,C.1s...... Mode of payment
For delivery by mail $/E ............ extra to be paid as postal charges for each passport'

l. (a) Full Name (expanded initials)

Surname, GUpTA
Given name R/AHUL

(b) Aliases, if any (Surname)

(c) applicant ever changed his/her name ? [s so, give previous name in full
RAHULKUMAR SURESHBHAI GUPTA
(d) Email id
rahulgupta@gmail.com PhNo 9725551212 9729998888
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2. Date of birth 05-DEC-1 975 Sex MALE o
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Place of birth SURRT z
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Country SURAT GUJARAT -) I

Height 156 (cms.) Colour of eyes BLACK @

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Color of Hair BLACK
Visible distinguishing marks, if any NIL
3. Permanent Address : I ntdl \6.1
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(a) To be 134 , PARK AVENUE, APT A2
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3l'ii"lo"n ALLEN' rx 75002
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(b) Other Adress -
423 SUDARSHAN SOCIETY
@
ADAJAN PATIA f
SURAT 390 032

4. (i) Name of Father SURESH GUPTA

Country of his birth INDIA
(ii) Name of Mother SARTTA GUPTA
Country of her birth INDIA

(iii) Nationality of Father at the time of applicant's birth INDIA

(iv) Nationality of Mother at the time of applicant's birth INDIA

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RAHUL GUPTA
5. Manied/Unmarried MARRIED

6. Name of Spouse MANISHA GUPTA

and Nationality INDIA
7. Particulars of person to be intimated in the event of death or accident:
Name ..... JYl.e..rtijfi.fl ....G .vI I k......
Address .. . .. I l. k . .. .P.M. ts...0rt fC. U f .,. . S/. L. fr..2.....
. ........0. L.L. & N..,...2 r(..... ?.r0 0.. .f ............
25.SEP-2002
8. Present Passport/ nationality, identity card, if any No. A99.7.Q9J9....Oate anO Place of issu. .+.|!Y.EP+.93P.

9. Local car driving Licence No. ./:(..|.1.f.1..r1........ Date and Place of issue ......9..?.:.? €.C.:..?.Q.t. f
10. Educational qualification BE
(In order to determine emigration status).

11. whendidapplicantfirst leavelndia? oL' FUG*lqq'7 whenwashe/she inlndia ,urr, ola-frPF- z 0lL
12. How long has applicant continuously resided abroad? ie \e**4
13. Present Emigration Status (ECR or ECNR) ECR
(With documentary evidence)
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t4. Profession and business F4
aooress ---|.+
Duslness address
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Bb, Piana
15. Please mention, if citizen of India by birth/descent/nationalization/Registration. E t ef \
16. Did applicant ever possess any other nationality or travel document of any other country? If so please
give detaits r\r 0
17. Was applicant ever refused an Indian Passport? (Yes@
18. Was applicant'passport ever impounded/revoked? If so, details please. ffe6o)
19. Name and address of two relatives/friends

(l) NrLr- sH k A /d0 A (2)

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P LAN0, f^ 1so ti 7 co\ttvL. T* 150t-'h
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20. Is applicant in Govt. Service/Public Undertaking Service/Statutory Bodies Service of India? If l

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21. (i) Are any criminal proceedings pending against applicant in any court in India? So, please
give ditaits ......... ......N0'.
(ii) Has applicant ever been repahiated frolqabroad to India at the expenses of the Govt. of
India ? If so, details please. ... .hJ. U

22. No. of lost/damaged passport f.l.q-........ place of issue

Date of issue . ...... Valid until .
23. (i) Briefly state circumstances of loss/thefl/damage of passport on a plain paper and attach
copy of report lodged with local police in case of loss/theft

(ii) Give details of restriction, if any, put on applicants's damaged/lost passport.

(iii) Did applicant avail transfer of residence, foreign travel scheme facility on lost/damaged
passport ? if so, details please

24. Is applicant registered with Indian Mission/Post ? If not, is he a member of any Indian N0
Organisation ?

25. Particulars of children, if any, to be deleted N i A-

Name Place & Date of birth (MiF)

Note : Separate passport will be issued to children of all ages. However, children below
l8 years of age will be given a 5-year maximum validity passport

26. DECLARATION :

I owe allegiance to the sovereignty, unity & integrity of India and have not voluntarily acquired the
citizenship or travel document of another country. I have not lost, surrendered or been deprived of
citizenship of India.
The information given by me is true and I am solely responsible for its accuracy. I am aware that it is an
offence under the Passport Act,1967 to fumish any false information or to suppress any material
information with a view to obtaining passport or any other travel document.

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in (oS e 0t Signature/Thumb Impression of applicant N
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loli / da*aged ('wt lar k- (Left Hand T.l. if male and right Hand T.l. if female) (o
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27.\n case of minors, following passport particulars of both parents must be given:
a
Father
f
Mother

(a) Passport No. :

(b) Dateof Issue:l-Tl m [TTn

(c) Place of Issue:

(d) Ifparents have applied for

A passport, please give
File No & date
2SDeclaration of Parents or Guardian if passport is for minor : (To be signed by both Parents or Guardian)

We affirm that the particulars given above are in respect of (Name)

Son / daughter of Smt. ......Sh.
of whom we are the Parents / Guardian. We undertake the entire responsibility for his/her expenses. We
solemnly declare that he/she has not lost, surrendered or been deprived of his/her citizenship of lndia and
that the information given in respect of him/her in this application is true. It is also certified that the name
of the child mentioned is not included in passport of either parent.

N
Mother Father Guardian
(o
N
Name & Signature/ T.l of both the Parents/Guardian (left hand T.l. if male and Right hand T.l .if female) N

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29. Specimen signature or T.l.within the Space given below :

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FOR OFFICE USE ONLY