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 Number 16-1004707837  
 
Applying For REISSUE

CHANGE IN EXISTING PERSONAL

If Re-issue, specify reason(s)
PARTICULARS

If change in existing personal

SPOUSE NAME
particulars, specify

Type of Application NORMAL

Type of Passport Booklet JUMBO

  
Applicant Details
Applicant's Name ABARNA VIJAYAKUMAR

Date of Birth (DD/MM/YYYY) 13/05/1993

Validity Required NA

Place of Birth (Village/Town/City) TRICHY

Signature/Left Hand Thumb Impression
District TRICHY RURAL of Illiterate Applicant and Minors who
cannot sign.
State/UT TAMIL NADU  
Country INDIA  
 
Gender FEMALE

Marital Status MARRIED

Citizenship of India by BIRTH

Employment Type HOME MAKER

Is either of your parent (in case of

N
minor)/spouse, a government servant?
Educational Qualification GRADUATE AND ABOVE

Are you eligible for Non-ECR category? Y

Aadhaar Number 399353388616

Family Details
Father's Name RAJASEKAR THIRUGNANASAMBANDHAM

Mother's Name JOTHI RAJASEKAR

Legal Guardian's Name VIJAYAKUMAR KARUNANIDHI

Spouse's Name VIJAYAKUMAR KARUNANIDHI

Present Residential Address Details
Residing Since(MM/YYYY) 05/1993

71.PRAKASH NAGAR.3RD STREET.THIRUVERUMBUR, TRICHY,

Address
THIRUVERUMBUR, TRICHY RURAL, TAMIL NADU

PIN 620013

Mobile/Tel No. 8903559470 / 04312510851

E-mail ABARNADR@GMAIL.COM

K.T.RAJASEKAR 71 PRAKASH NAGAR 3RD STREET

First Reference Name And Address
THIRUVERUMBUR TRICHY 13

Mobile/Tel No. 9442419970

T.SIVANANTHAM 69 PRAKASH NAGAR 3RD STREET

Second Reference Name And Address
THIRUVERUMBUR TRICHY 13

Mobile/Tel No. 9443097636

Permanent Residential Address
71.PRAKASH NAGAR.3RD STREET.THIRUVERUMBUR, TRICHY,
Address
THIRUVERUMBUR, TRICHY RURAL, TAMIL NADU

PIN 620013

Mobile/Tel No. 8903559470 / 04312510851

Emergency Contact Details
K.T.RAJASEKAR 71 PRAKASH NAGAR 3RD STREET
Name and Address
THIRUVERUMBUR TRICHY-13

Mobile/Tel No. 9443764229

E-mail KTRSEKARBHEL@GMAIL.COM
Previous Passport/ Application Details
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number K7802176

Date of Issue 22/04/2013

Date of Expiry 21/04/2023

Place of Issue TRICHY

File Number TR2061870152113

Payment Details

Mode of Payment Online/Internet Banking

Date 31/05/2016

Receipt/Reference No. IG0CBXMQD2

Amount Received (Rs.) 2000.00  (TWO THOUSAND ONLY)

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.

Place TRICHY Signature/Left Hand Thumb Impression of

Applicant (If applicant is minor, either parent
Date 23/05/2016 to sign)