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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

161010897697

ApplyingFor

FRESH

TypeofApplication

NORMAL

TypeofPassportBooklet

JUMBO

ApplicantDetails
Applicant'sName

PAVANKUMARCHENNAPRAGADA

DateofBirth(DD/MM/YYYY)

03/03/1988

ValidityRequired

NA

PlaceofBirth(Village/Town/City)

BSAVARAM

District

EASTGODAVARI

State/UT

ANDHRAPRADESH

Country

INDIA

Gender

MALE

MaritalStatus

SINGLE

CitizenshipofIndiaby

BIRTH

PAN

AMWPC6328B

EmploymentType

PRIVATE

Iseitherofyourparent(incaseof
minor)/spouse,agovernmentservant?

EducationalQualification

GRADUATEANDABOVE

Signature/LeftHandThumbImpression
ofIlliterateApplicantandMinorswho
cannotsign.

AreyoueligibleforNonECRcategory? Y
AadhaarNumber

716003988450

FamilyDetails
Father'sName

SHYAMASUNDARARAMMOHANRAOCHENNAPRAGADA

Mother'sName

UMAMAHESHWARICHENNAPRAGADA

PresentResidentialAddressDetails
ResidingSince(MM/YYYY)

03/1988

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Address

296,OLDCOLONY,KAGHAZNAGAR,KAGHAZNAGAR
TOWN,KOMARAMBHEEMASIFABAD,TELANGANA

PIN

504296

Mobile/TelNo.

9492385357

Email

PAVANEEE11@GMAIL.COM

FirstReferenceNameAndAddress

M.SHIVARAMKRISHNA

Mobile/TelNo.

9908748215

SecondReferenceNameAndAddress

M.SATYANARAYANA

Mobile/TelNo.

9848375393

PermanentResidentialAddress
Address

296,OLDCOLONY,KAGHAZNAGAR,KAGHAZNAGAR
TOWN,KOMARAMBHEEMASIFABAD,TELANGANA

PIN

504296

Mobile/TelNo.

9492385357

EmergencyContactDetails
NameandAddress

CHSSRMOHANRAO

Mobile/TelNo.

9603709036

FeeDetails(NottobefilledbyapplicantssubmittingtheapplicationatPassportSevaKendra/PassportOffice)
Feeamountin(Rs)

IfpaidbyDemandDraft(DD),providethefollowingdetails
DDIssueDate(dd/mm/yyyy)

DDExpiryDate(dd/mm/yyyy)

BankName

Branch

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

HYDERABAD

Date

02/01/2017

Signature/LeftHandThumbImpressionof
Applicant(Ifapplicantisminor,either
parenttosign)

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