File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS

PASSPORT SURRENDER CERTIFICATE APPLICATION 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 latest Indian Passport at the time of submission of this form.

1. Passport Details

1.1 Passport Number 1.2 Date of Issue (DD-MM-YYYY) Please paste your
unsigned recent
- - colour photograph
with white
background of size
1.3 Date of Expiry (DD-MM-YYYY) - - 4.5cm X 3.5cm

1.4 Place of Issue

2. Surrender Details
Signature/ Left Hand Thumb
Impression of Illiterate
2.1 Reason for Surrender Applicant and Minors who
cannot sign.
Acquiring Foreign Nationality/ Renunciation of Indian Citizenship
2.2 Applicant's Nationality (Region/Country Name)

2.3 Foreign Nationality Acquisition Date (DD-MM-YYYY) - -

(Please attach a copy of foreign nationality proof)

3. Applicant Details

3.1 Applicant's Given Name (Given Name means First name followed by Middle name (If any))(Initials not allowed)

Surname

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3.2 Date of Birth (DD-MM-YYYY) - -

3.3 Place of Birth

District

State/ UT

Birth Region/Country (If born abroad) If born before 15/08/1947 in a place now in Pakistan or Bangladesh, write
"Undivided India"

3.4 Gender Male Female Transgender

3.5 Marital Status Single Married Divorced Widow/ Widower Separated
3.6 Educational Qualification

7th pass or less Between 8th and 9th Standard

10th pass and above Graduate and above

3.7 Mark of Identification

4. Family Details

4.1 Father's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)

Surname

4.2 Mother's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)

Surname

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4.3 Spouse's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)

Surname

4.4 Spouse's Nationality (Country Name)

4.5 Legal Guardian's Given Name (If applicable) (Initials not allowed)

Surname

5. Present Residential Address Details

5.1 House No. and Street Name

Village or Town or City

District (If in India)

State/ UT (If in India)

PIN Telephone Number

Mobile Number E-mail ID

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6. Emergency Contact Details

6.1 Name and Address

Mobile Number Telephone Number

7. Enclosures
1. 4.
2. 5.
3. 6.
8. Self Declaration
I affirm that the information given by me in this form and the enclosure is true and I am solely responsible for
its accuracy and I am liable to be penalised or prosecuted if found otherwise. I am aware that under
Passports Act, 1967 it is a criminal offence to furnish any false information or to suppress any material
information to the Passport Authority.

Place Signature/ Left Hand

Thumb Impression of
Applicant (If applicant is
minor, either parent to
Date (DD-MM-YYYY) sign)

- -

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