Signature or thumb impression

should be within the box only.

1. Surname ARUMUGAM
Given Name VN!A"SAN
Aliases# i$ any Gender Male % x & ' (emale % &
)as appli*ant ever *hanged his'her name + ,$ so# give previous name in $ull-
Maiden Name# i$ appli*ant is a married woman-
.. /resent passport No. 0.121342 5ate o$ ,ssue ..6216.211
/la*e o$ ,ssue R,7A5) Validity
8. 5ate o$ 9irth 2862.6141. /la*e : ;ountry o$ 9irth SA,5A/"# ARN, # "AM,<NA5U
)eight %;ms& 1=> ;olour o$ yes 9<A;! ;olour o$ )air 9<A;!
?. (ather@s Name ARN, MURUGSAN ARUMUGAM MU5A<,AR
Nationality o$ $ather at the time o$ appli*antAs birth- ,N5,AN ;ountry o$ his birth ,N5,A
>. Mother@s Name ARUMUGAM /BVUNAMMA<
Nationality o$ mother at the time o$ appli*antAs birth- ,N5,AN ;ountry o$ his birth ,N5,A
1. Married % x &'Unmarried % & )usband'Ci$e@s Name : Nationality ,N5,AN
=. ,n *ase o$ Minor- (atherAs passport No. 666 5ate : /la*e o$ ,ssue 6666
MotherAs passport No. 66666 5ate : /la*e o$ ,ssue 66666
3.
/resent *omplete physi*al address
in !.S.A with name o$ street et*.
ANN,AN S"R"# DU9A,< 5BCN"BCN. NAR S),(A M5,;A< ;N"R.
"el. B$$i*e 2188>3>11> Res. 218811>148 Mobile 2>2.31?.23
4. /ermanent Address in ,ndia ?.1?9 SR A/AR"MN"# .
N5
;RBSS S"R"
SS)A5R,/URAM# V<A;)R76 ;)NNA,61222?.
;ity'State "AM,<NA5U "el. No. 224144?28>.8>?
12. du*ational Euali$i*ation 9.. F;)M,;A< /ro$ession ;)M,;A< NG,NR,NG
11. Sponsor@s name# ,5 and tel.no.- ARA9,AN AM,N ;BM/AN7' ,EAMA6 ..=8?43??2' 2188>3>122
1.. Chen did appli*ant $irst leave ,ndia .22. Chen was he'she last in ,ndia- B;"'Nov .218
5o not write below this line.
6666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666
"his $orm is $ree o$ *harge. /hoto*opy o$ this $orm is a**eptable. "he $orm may also be downloaded $rom our web site-
www.indianembassy.org.sa . ,$ there is a *hange'addition in any parti*ular su*h as address# spouse name et*. please also submit the
Mis*ellaneous $orm %(orm .& with do*umentary proo$. ,$ ne*essary# *learan*e shall be sought o$ the *on*erned authorities in ,ndia be$ore
the servi*e is rendered.
mbassy o$ ,ndia
Riyadh
/assport Appli*ation (orm
1. "his $orm is $or issue o$ $resh passport and all
*ases where a new passport booGlet is reHuired.
.. /lease $ill the $orm in 9<B;! <etters : ea*h
*olumn o$ it. Crite ANAA where not appli*able.
8. 9ring altogether 8.> x ?.>*m three *olour photos
with light ba*Gground# out o$ whi*h paste %not
staple& one on the designated pla*e in the $orm.
?. 9ring old passport in Briginal and *opy o$ ,Hama.
%,n *ase Given Name ex*eeds 82 *hara*ters# part
o$ the given name may be adIusted with Surname&
/aste (NOT STAPLE) one
photo here. SiJe o$ the
photo should be 8.>*m x
?.>*m.%with $ull $rontal view
o$ the $a*e and no side pose
photo&
/hotos should be in *olour
with light ba*Gground only :
without white borders.
(BR B((,; US BN<7
(ile No. -
Re*eipt No. -
Amt.
/pt. No. -
5o,-
Validity-
(orm ,
6 . F

18. )ow long has appli*ant *ontinuously resided abroad+ 12
1?. /lease mention# i$ *itiJen o$ ,ndia by 9irth'5es*ent'NaturaliJation'Registration. 9y birth
1>. 5id appli*ant ever possess any other nationality or travel do*ument o$ any other *ountry# i$ so# please give details-
NB
11. Cas appli*ant ever re$used an ,ndian passport + %7es'No& NB
1=. Cas appli*antAs passport ever impounded'revoGed + ,$ so# details please. %7es'No& NB
13. Name and address o$ two relatives'$riends in !.S.A ' ,ndia-
%i& V.SN,VASAN 6 2>221>12=? %ii& V.!AR"),!RADAN6 4=343?42?=
N.DVA6 2>2=3.8>4> A.7UVARAD!UMAR6 434?1.41=.
14.
,s appli*ant in Govt. Servi*e'/ubli* UndertaGing Servi*e'Statutory 9odies Servi*es o$ ,ndia+ ,$ so# please give
details and en*lose ANo obIe*tion *erti$i*ateA $rom you employer in original. N'A
.2.
%i& Are any *riminal pro*eedings pending against the appli*ant in any *ourt in ,ndia+ ,$ so# please give details - N'A
%ii& )as appli*ant ever been repatriated $rom abroad to ,ndia at the expenses o$ the Govt. o$ ,ndia+ ,$ so please give
details - N'A
.1. No. o$ lost'damaged passport N/A 5ate o$ issue N/A
/la*e o$ issue N/A Valid Until N/A
...
%i& 9rie$ly state *ir*umstan*es o$ loss'the$t'damage o$ passport on a plain paper and atta*h *opy o$ report lodged
with lo*al poli*e in *ase o$ loss'the$t. N'A
%ii& Give details o$ restri*tion# i$ any# put in appli*antAs damaged'lost passport.
%ii& 5id appli*ant avail trans$er o$ residen*e# $oreign travel s*heme $a*ility on lost'damaged passport+ ,$ so# details
please
.8. ,s appli*ant registered with ,ndian Mission'/ost + ,$ not# is he a member o$ any ,ndian Brganisation +
N/A
.?. Next o$ Gin'$riend to *onta*t in *ase o$ emergen*y-
,n !SA ,n ,ndia
Name N. DVA# /RB5U;",BN NG,NR A.7UVARAD!UMAR
;omplete address AM,NA"6 /.B 9BK 111?2 /<B" NB6??6 GRBUN5 (<BBR#
DU9A,< ,N5 .;,"76 81411 SUN5AR NAGAR6 ;)NNA,61222>1
/hone %land6line : mobile& 2>2=3.8>4> 2241434?1.41=.
5;<ARA",BN - , solemnly a$$irm that - %i& , owe allegian*e to the sovereignty and integrity o$ ,ndia# and %ii& ,n$ormation
given above in respe*t o$ mysel$# my son'daughter'ward is *orre*t and nothing has been *on*ealed and , am aware that it
is an o$$en*e under the /assport A*t# 141= to Gnowingly $urnish $alse in$ormation or suppress material in$ormation# whi*h
attra*t penal and other punishments under the a*ts# and %iii& , undertaGe to be entirely responsible $or expenses o$ my
son'daughter'ward.
Please sign here
/la*e
5ate Signature or ".,. o$ the appli*ant or his legal guardian
or $ather : mother BOTH in *ase o$ minor *hild %<e$t hand ".,. o$ male and right hand ".,. o$ $emale&
Spe*imen signature or ".,. o$ the appli*ant
within the two boxes below-
In case change of signatures, kindly make
your old signature here