10/25/13

Application Form

PASSPORT APPLICATION FORM

Government of INDIA,Ministry of External Affairs
Service Required
Application Reference Number
Applying For
Type of Application
Type of Passport Booklet
Validity Required

13-1009727187
FRESH
NORMAL
NORMAL
NA

Applicant Details
Applicant's Name
Date of Birth (DD/MM/YYYY)
Place of Birth (Village/Town/City)
District
State/UT
Country
Gender
Marital Status
Citizenship of India by
PAN
Employment Type
Is either of your parent (in case of
minor)/spouse, a government servant?
Educational Qualification
Are you eligible for Non-ECR category?
Visible Distinguishing Mark
Aadhaar Number

LOVA RAJU BALAM

23/06/1992
MADHAVARAM
WEST GODAVARI
ANDHRA PRADESH
INDIA
MALE
SINGLE
BIRTH
BEFPB3344L
STUDENT
N
GRADUATE AND ABOVE
Y
A MOLE ON LEFT HAND RNG FINGER
613097390923

Family Details
Father's Name
Mother's Name

SATYA VENKATA SATYANARAYANA BALAM

GANGA BHAVANI VEMPALI

Present Address Details

Residing Since(MM/YYYY)
Address
PIN
Mobile/Tel No
E-mail
First Reference Name And Address
Mobile/Tel No
Second Reference Name And Address
Mobile/Tel No

06/1992
8-24-7/2, ALLA RATHYA STREET, JUVVALAPALEM TADEPALLIGUDEM ANDHRA
PRADESH WEST GODAVARI TADEPALLIGUDEM TOWN
534102
9491022253
BALAMLOVARAJU@GMAIL.COM
VEMPALI AMMI RAJU, S/O:V.SUBBARAO, DR.NO:8-24-10, ALLA RATHYA STREET,
TADEPALLIGUDEM 534101.
9493089578
MADDUKURI MARKENDYULU, S.O M.ANJENEYULU DR.NO 8-24-12, ALLA
RATHYA STREET, TADEPALLIGUDEM,534101.
9000898531

Permanent Address
Address
PIN
Mobile/Tel No

8-24-7/2, ALLA RATHYA STREET, JUVVALAPALEM TADEPALLIGUDEM ANDHRA

PRADESH WEST GODAVARI TADEPALLIGUDEM TOWN
534102
9491022253

Emergency Contact Details

Name and Address
Mobile/Tel No
Mobile/Tel No

BALAM SATYA VENKATA SATYANARAYANA, ALLA RATHYA STREET,

JUVVALAPALEM,TADEPALLIGUDEM,WEST GODAVARI
8985826038
8985826038

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction

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10/25/13

Application Form

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 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
TADEPALLIGUDEM
Date
25/10/2013

https://portal2.passportindia.gov.in/AppOnlineProject/secure/ApplicantSelfDeclarationAction

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