APPLICATION FORM FOR PASSPORT ONLINE REGISTRATION

Surname: _______________________________________________________________________________
Given Name: ____________________________________________________________________________
Have you ever change your name if yes pls write your previous name
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Sex: Male/Female _______________

Date of Birth: ________________________________________

Place of Birth
Town/village: _____________________

Dist: _______________________ State: _________________

Qualification: ___________________________________________________________________________
Profession: _____________________________________

Height in cm: _________________________

Visible Mark: ___________________________________________________________________________

Present Address: _________________________________________________________________________
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If you have not resided at present address continuously for last one year pls furnish other address with
duration (date)
From _______________ to ________________
From _______________ to ___________________
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Permanent Address: _____________________________________________________________________
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Residing since at present address (Date): _________________________________________
Telephone No (R) _________________ (O) ___________________

Mobile No: ___________________

Email ID: ______________________________________________________________________________

Husband/Wife Name: ____________________________________________________________________
Father Name: ___________________________________________________________________________
Mother Name: __________________________________________________________________________
Old Passport No: _______________________________ Date of Issue: __________________________
Place of issue: __________________________________ File No: _______________________________
Date of Expiry: ________________________
Name & Address of Two responsible people in your locality
1) Name: ________________________________ 2) Name: _________________________________
Address: ________________________________ Address: _________________________________
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Tel/mobile: ________________________________ Tel/mobile: ________________________________

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(Signature of Applicant)