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 12-0003398822 Number Applying For FRESH Type of Application NORMAL Type of Passport NORMAL Booklet Validity Required Applicant Details ARUN KUMAR Applicant's Name SAHANI Date of Birth 15/04/1987 (DD/MM/YYYY) Place of Birth SHAKTINAGAR (Village/Town/City) District SONBHADRA State/UT UTTAR PRADESH Country INDIA Gender MALE Marital Status SINGLE Signature/Left Hand Thumb Impression Citizenship of India by BIRTH of Illiterate Applicant and Minors who Employment Type PRIVATE cannot sign. Is either of your parent (in case of minor)/ Y spouse, a government servant? Educational GRADUATE AND Qualification ABOVE Are you eligible for Y Non-ECR category? Visible Distinguishing ONE MOLE ON Mark RIGHT EAR Family Details Father's Name KALLU RAM Mother's Name MANNO DEVI Legal Guardian's Name KALLU RAM

Present Address Details Residing Since(MM/YYYY) Address PIN Mobile/Tel No Email First Reference Name And Address Mobile/Tel No Second Reference Name And Address Mobile/Tel No Permanent Address Address PIN Mobile/Tel No Emergency Contact Details Name and Address

08/2011 91/237 FIRST FLOOR PAL HOUSE & MALKAGANJ GUDMANDI DELHI NORTH DELHI ROOPNAGAR 110007 09911629692 aman2005ind@gmail.com ARUN KUMAR & Q.TO.NO I.B 179 VIDUT VIHAR COLONY NTPC SHAKTINAGR ,SONEBHARA(U.P)-231222. 09453007554 / 05446238263 ARUN KUMAR & H.NO 91/237 PAL HOUSE RAJPURA GUDMANDI NEAR PAL CHOWK, STREET-MALKAGANJ ,NEW DELHI 110007 09911629692 I.B 179 V.V NTPC COLONY SHAKTINAGAR SHAKTINAGAR UTTAR PRADESH SONBHADRA India SHAKTINAGAR 231222 09911629692 ARUN KUMAR & H.NO 91/237 PAL HOUSE RAJPURA GUDMANDI NEAR PAL CHOWK, STREET-MALKAGANJ ,NEW DELHI 110007 09911629692 aman2005ind@gmail.com

Mobile/Tel No Email Other Details Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra) 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. 6. 2. 7. 3. 8. 4. 9. 5. 10.

Self Declaration I owe allegiance to the sovereignty, unity and 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 and I affirm that the information given by me in this form and the enclosures is true and I am solely responsible for its accuracy, and 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. Signature/Left Hand Thumb Place NEW DELHI Impression of Applicant (If Date 12/12/2012 applicant is minor, either parent to sign)