anil_print submitted form
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Anil_Print Submitted FormTRANSCRIPT
12/17/2014 View/Print Submitted Form
https://portal2.passportindia.gov.in/AppOnlineProject/secure/ViewDraftAction?arn=141008574365 1/3
File Number (For Office Use Only)
Service Required
Application Reference Number 141008574365
Applying For FRESH
Type of Application NORMAL
Type of Passport Booklet NORMAL
Validity Required NA
Applicant Details
Applicant's Name ANIL CHANDRA DAS
Date of Birth (DD/MM/YYYY) 07/12/1965
Place of Birth (Village/Town/City) KOLKATA
District NORTH 24 PARGANAS
State/UT WEST BENGAL
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
PAN AEXPD0423R
Voter Id KTF2747798
Employment Type PRIVATE
Is either of your parent (in case ofminor)/spouse, a government servant?
N
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for NonECR category? Y
Visible Distinguishing Mark A CUT IN THE RIGHT EYE SIDE
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.
Signature/Left Hand Thumb Impressionof Illiterate Applicant and Minors who
cannot sign.
Family Details
Father's Name NIRMAL CHANDRA DAS
Mother's Name SOVA RANI DAS
Spouse's Name SWAPNA DAS
Present Address Details
Residing Since(MM/YYYY) 07/1968
12/17/2014 View/Print Submitted Form
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Address88 PRAN KRISHNA SAHA LANE, BARANAGAR, KOLKATA,BARANAGAR PS, BARRACKPORE , WEST BENGAL
PIN 700036
Mobile/Tel No. 9002105598
Email [email protected]
First Reference Name And AddressSUSHIL CHANDRA DAS, HALDIA PETROCHEMICALSLIMITED, DURGA CHOWK, HALDIA
Mobile/Tel No. 9434017061
Second Reference Name And AddressTAPAN ROY, 4K NATURAL VIEW, 82 ULTADANGA MAINROAD, KOLKATA 700067
Mobile/Tel No. 8274974811
Permanent Address
Address88 PRAN KRISHNA SAHA LANE, BARANAGAR, KOLKATA,BARANAGAR PS, BARRACKPORE , WEST BENGAL
PIN 700036
Mobile/Tel No. 9002105598
Emergency Contact Details
Name and AddressSWAPNA DAS, 88 PRAN KRISHNA SAHA LANE,BARANAGAR, KOLKATA 700036
Mobile/Tel No. 9903958943 / 03325775891
If you have held/hold any diplomatic/official passport, provide details
Passport Number A6264613
Date of Issue 09/10/1998
Date of Expiry 08/10/2008
Place of Issue CALCUTTA
Payment Details
Mode of Payment Challan
Date 14/10/2014
Receipt/Reference No. 5979084
Amount Received (Rs.) 1500.00 (ONE THOUSAND FIVE HUNDRED 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.
12/17/2014 View/Print Submitted Form
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Place KOLKATA
Date 12/10/2014
Signature/Left Hand Thumb Impression ofApplicant (If applicant is minor, eitherparent to sign)