7/19/2017 Application Form

PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 17-0010427828
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED MORE THAN 3 YEARS AGO
Type of Application NORMAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name VIBHOR MITTAL
Date of Birth (DD/MM/YYYY) 22/02/1996
Validity Required 10 Years
Place of Birth (Village/Town/City) SHAMLI
District MUZAFFARNAGAR
State/UT UTTAR PRADESH
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN DEVPM3900P
Employment Type STUDENT
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? N
Aadhaar Number 415806443922
Family Details
Father's Name SATISH KUMAR MITTAL
Mother's Name BABITA MITTAL
Present Residential Address Details
Residing Since(MM/YYYY) 07/2004
C-12,MAYUR NAGAR, LODHA, KOTWALI BANSWARA, BANSWARA,
Address
RAJASTHAN
PIN 327001
Mobile/Tel No. 8852883156 / 8114468929
E-mail VIBHORMITTAL222@GMAIL.COM
First Reference Name And Address RK GAGRANI,C-13,MAYUR NAGAR,LODHA BANSWARA-327001
Mobile/Tel No. 9414005108
Second Reference Name And Address BC GUPTA,B-3,MAYUR NAGAR,LODHA,BANSWARA-327001
Mobile/Tel No. 9414005103
Emergency Contact Details
SATISH KUMAR MITTAL,C-12,MAYUR NAGAR,LODHA,BANSWARA-
Name and Address
327001,RAJASTHAN
Mobile/Tel No. 9414103989 / 02962304207
E-mail SKMITTAL@LNJBHILWARA.COM
Previous Passport/ Application Details
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number A9082130
Date of Issue 01/11/2000
Date of Expiry 31/10/2005
Place of Issue JALANDHAR
Other Details
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

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7/19/2017 Application Form

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.
Place BANSWARA
Date 19/07/2017

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