PASSPORT APPLICATION FORM

Government of INDIA, Ministry of External Affairs

Service Required
Application Reference Number 19-0003208348
Applying For FRESH
Type of Application TATKAAL
Type of Passport Booklet NORMAL
Applicant Details
Applicant's Name DECHEN PEMBA
Date of Birth (DD/MM/YYYY) 04/01/1992
Validity Required NA
Place of Birth (Village/Town/City) TASHIGONG
District UPPER SIANG
State/UT ARUNACHAL PRADESH
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type SELF EMPLOYED
Is either of your parent (in case of minor)/spouse, a government
N
servant?
Educational Qualification 7TH PASS OR LESS
Are you eligible for Non-ECR category? N
Visible Distinguishing Mark SCAR ON LEFT CHEEK
Aadhaar Number 509568451165
Family Details
Father's Name JURME RENZIN
Mother's Name DAWA CHOIDEN
Spouse's Name REMI MELLO
Present Residential Address Details
Address S/O: JURME RENZIN, TASHIGONG, TUTING, TUTING, TUTING, UPPER SIANG, ARUNACHAL PRADESH
PIN 792061
Mobile/Tel No. 7005256907 / 9436430209
E-mail DPKHAMBA1234@GMAIL.COM
Permanent Residential Address
Address S/O: JURME RENZIN, TASHIGONG, TUTING, TUTING, TUTING, UPPER SIANG, ARUNACHAL PRADESH
PIN 792061
Mobile/Tel No. 7005256907 / 9436430209
Emergency Contact Details
MOYONG STORE AND CONSTRUCTION AGENCIES, MIR MIR TINALI, PASIGHAT, EAST SIANG , ARUNACHAL
Name and Address
PRADESH
Mobile/Tel No. 8257899185 / 9862232861
E-mail ZANDEA2012@GMAIL.COM
Other Details
Enclosures
1.Aadhaar Card/E-Aadhaar
2.Aadhaar Card/e-Aadhar containing the 12 digit Aadhaar number issued by the Unique Identification Authority of India(UIDAI)
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.
Place PASIGHAT
Date 05/03/2019
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