APPLICATION FORM FOR INDIAN PASSPORT Page 1 of 5

CONSULATE GENERAL OF INDIA

17 RUTLAND SQUARE, EDINBURGH, EH1 2BB, SCOTLAND,
UNITED KINGDOM
00-44-131-2292144, https://www.cgiedinburgh.gov.in/
APPLICATION FORM FOR INDIAN PASSPORT
PASSPORT PREVIEW Generated On: 18/06/2021 14:21:35

��रत गणर�ज्य REPUBLIC OF INDIA

��इप/Type र��� क�ड/CountryCode प�सप��� न�./PassportNo.

Paste your unsigned recent P IND

color photograph Size उपन�म/Surname

2"X2" and Signature/Left KUMAR

Hand Thumb Impression in ��य� गय� न�म/Given Name(s)

the box provided below XYZ

र����य��/Nationality �ल�ग/Sex जन्म����/Date of Birth

INDIAN M 12/04/1986
जन्म ���न/Place of Birth

RAIPUR, UTTAR PRADESH

ज�र� करन� क� ���न/Place of Issue

ज�र� करन� क� ����/Date of Issue सम��� क� ����/Date of Expiry

�प��/क�न�न� अ����वक क� न�म/Name of Father/Legal Guardian

SUNIL DAYANAND KUMAR

म��� क� न�म/Name of Mother

KUSUM LATA KUMAR

प�� य� प�� क� न�म/Name of Spouse

प��/Address

FLAT 105, ROHNI BIULDING, C.B. GANJ

RAIPUR, BAREILLY

PIN:243123, UTTAR PRADESH, INDIA

प�र�न� प�सप��� क� न�. और इसक� ज�र� ��न� क� ���� एव� ���न/Old Passport No with Date and Place of Issue

G000000 11/02/2011 LUCKNOW

��इल न�./File No.

Note: Please paste your unsigned recent color photograph Size 2"X2" and Signature/Left Hand Thumb Impression in the box
provided above.

SERVICE REQUIRED
Application Reference Number 21-2002186596
Applying For REISSUE
If Re-issue, specify reason(s) VALIDITY EXPIRED WITHIN 3 YEARS/DUE TO EXPIRE.
If change in existing personal particulars, specify
If other, specify
Type of Application NORMAL
Type of Passport Booklet 36 Pages

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APPLICATION FORM FOR INDIAN PASSPORT Page 2 of 5

APPLICANT DETAILS
Applicant's Name XYZ KUMAR
Applicant's Alias Name N
Alias Name1
Alias Name2
Applicant's Change In Name N
Previous Name1
Previous Name2
Date of Birth (DD/MM/YYYY) 12/04/1986
Validity Required NA
Place of Birth (Village/Town/City) RAIPUR
District BAREILLY
State/UT UTTAR PRADESH
Country INDIA
Gender MALE
Marital Status SINGLE
Citizenship of India by BIRTH
PAN
Voter Id
Employment Type PRIVATE
Organisation name
Is either of your parent (in case of minor)/spouse, a
N
government servant?
Educational Qualification GRADUATE AND ABOVE
Are you eligible for Non-ECR category? N
Visible Distinguishing Mark
Aadhaar Number

FAMILY DETAILS
Father's Name SUNIL DAYANAND KUMAR
Mother's Name KUSUM LATA KUMAR
Legal Guardian's Name
Spouse's Name
Father's Passport No
Father's Nationality
Mother's Passport No
Mothers's Nationality
PASSPORT PRINTABLE ADDRESS DETAILS
FLAT 105, ROHNI BIULDING, C.B. GANJ
To be printed on passport RAIPUR, BAREILLY
PIN:243123, UTTAR PRADESH, INDIA
Mobile/Tel No. 9100000000000
E-mail XYZ@GMAIL.COM
OTHER ADDRESS DETAILS
2/2
Address 125 ROSEWILL STREET
BN14 1ET, UNITED KINGDOM
Mobile/Tel No. 4400000000000
EMERGENCY CONTACT DETAILS

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APPLICATION FORM FOR INDIAN PASSPORT Page 3 of 5

Name and Address ZBC

Mobile/Tel No. 440000000000
E-mail
PREVIOUS PASSPORT
DETAILS OF LATEST
HELD/EXISTING/LOST/DAMAGED
Y
ORDINARY PASSPORT/ IDENTITY
CERTIFICATE
Passport Number G000000
Date of Issue 11/02/2011
Date of Expiry 13/03/2021
Place of Issue LUCKNOW
File Number 0000000000000
HAVE YOU EVER APPLIED FOR PASSPORT, BUT
N
NOT ISSUED?
File Number
Date of Issue
Name of passport office where applied
DETAILS OF PREVIOUS/CURRENT
N
DIPLOMATIC/OFFICIAL PASSPORT
Passport Number
Date of Issue
Date of Expiry
Place of Issue
1) Provide the following details if there are any criminal
proceedings pending against the applicant.
1.1) Are any proceedings in respect of an offence alleged to
have been committed by you pending before a criminal court in N
India?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.2) Has any warrant or summons for your appearance been
issued and pending before a court under any law for the time N
being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.3) Has a warrant for your arrest been issued by a court under
N
any law for the time being in force?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)
1.4) Has an order prohibiting your departure from India been
N
made by any court?
Court Name and Place
Case/FIR/Warrant Number
Law and Section(s)

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APPLICATION FORM FOR INDIAN PASSPORT Page 4 of 5

2) Provide the following details if the applicant has been

convicted by a court in India.
2.1) Have you at any time during the period of five years
immediately preceding the date of this application been
convicted by a court in India for any offence involving moral N
turpitude and sentenced in respect thereof to imprisonment for
not less than two years?
Court Name and Place
Case/FIR/Warrant Number
Date of Conviction
3) Provide the following details if the applicant has been
refused/denied passport.
3.1) Have you ever been refused/denied passport? N
Reason for refusal or denial of passport
3.2) Has your passport ever been impounded? N
Passport Number
Reason for impounding/revocation
3.3) Has your passport ever been revoked? N
Passport Number
Reason for revocation
4) Provide the following details if applicant has applied for or
been granted foreign citizenship.
4.1) Have you ever applied for or been granted citizenship by
N
any other country?
Name of the country
4.2) Have you ever held the passport of any other country at
N
any time?
Name of the country
4.3) Have you ever surrendered your Indian passport? N
Surrendered Indian passport number:
4.4) Have you ever applied for renunciation of Indian
N
citizenship?
Application Details:
Name of place where application submitted:
5) Provide the following details if applicant has returned to
India on Emergency Certificate.
5.1) Have you ever returned to India on Emergency Certificate
N
(EC)?
EC No.
Date of Issue
Issuing Authority
Country from where travelled on EC/deported/repatriated
Date of Return to India
Reason for issuing EC/deported/ repatriated
5.2) Have you ever been deported from any country? N
If yes, was the cost borne by the Government of India and if
so, has the same been refunded?
5.3) Have you ever been repatriated from any country back to
N
India?

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APPLICATION FORM FOR INDIAN PASSPORT Page 5 of 5

If yes, was the cost borne by the Government of India and if

so, has the same been refunded?
SELF DECLARATION
I declare:

• I owe allegiance to the sovereignty, unity & 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. I

have not contravened any of the conditions relating to the possession and use of an Indian passport.
I affirm that the information and particulars given by me in this form are true and correct. I further state that I am

not suppressing any material information in this regard. I further affirm that the enclosures and documentary

proof submitted in support of my application for an Indian passport are authentic and solely pertain to me and I

am fully responsible for the accuracy of the same. 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.

I have read and understood the contents of the above and by submitting this form certify that all the information

submitted by me in the form is bonafide.

I understand:

• That Ministry of External Affairs (MEA) (or its implementation partner agencies/stakeholders/third parties) may

undertake required checks to confirm the accuracy and authenticity of evidence I have provided and documents I

have submitted with this application.

• That the information I provide, including biometric data (if any), will be treated in confidence, but it may be
disclosed to other government departments, agencies, local authorities, foreign governments, and other

implementation partner agencies/stakeholders/third parties to enable MEA or those bodies to perform their
duties.

• That providing biometric information, if collected as part of an application, is confirmation of my consent to getting

the biometric information checked to verify identity.

• That the Passport and related services applications may be handled by the Indian Embassies/Consulates/

Passport Office/other offices including outside of the country in which I have applied and that this may involve the
transfer of my application and supporting documents to and from the respective offices.

• That my details may, in certain circumstances, be passed to Police, Intelligence and other Fraud Detection &
Prevention agencies. I also understand that such agencies may provide related information about me to MEA.

Place EDINBURGH Signature/Left Hand Thumb Impression of Applicant

(If applicant is minor, either parent to sign)
Date 18/06/2021

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