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CONSULATE GENERAL OF INDIA
3 East, 64th Street (Bet. Madison and Fifth Ave.), New York, N.Y. 10021
Tel: (212)774-0600.Fax (212) 570-9581
[email protected]

APPLICATION FOR AN INDIAN PASSPORT

THIS FORM IS FOR THE ISSUE OF FRESH/AFTER 10 YEARS (FINAL) AND FOR DUPLICATE PASSPORT

(PLEASE REFER TO SERIAL NO. 12 OF THE INSTRUCTIONS)

FEE PAID $:_______ EMERGENCY FEE $:_______ POSTAL CHARGES $:______ TELEX CHARGES $:_______

MODE OF PAYMENT : CASH/CERT. CHECK/M.O. _____________________________

1. (a)FULL NAME(Expanded initials)__________________________________________________
                                                                          (First)             (Middle)                     (Last)

(b) Aliases, if any ____________________________________________

(c) Have you ever changed your name? (Yes/No) _________

If yes, please write your name in full ______________________________________________

(d) Maiden name, in case applicant is a married woman ______________________________

2. YOUR PLACE OF BIRTH__________ 3. COUNTRY OF BIRTH ________ 4. DATE OF BIRTH_____________

(DD) (MM) (YY)

5. SEX ______ 6.Color of eyes _________ 7. Color of hair _________ 8. Height _________

9. VISIBLE DISTINGUISHING MARKS, IF ANY _______________________________

10. MARITAL STATUS________ 11. PROFESSION_____________________________

12. BUSINESS/OFFICE ADDRESS: _________________________________

______________________________________ TEL. NO. ______________________

13.FULL NAME OF HUSBAND________________NATIONALITY________________

TEL NO:______________________

14.FULL NAME OF WIFE____________________    NATIONALITY_______________

TEL NO:_____________________

15. (a) FULL NAME OF FATHER_____________________________COUNTRY OF HIS BIRTH_____________

(b) FULL NAME OF MOTHER____________________________COUNTRY OF HER BIRTH____________

(c) Nationality of father at the time of applicant's birth_______________________________

(d) Nationality of mother at the time of applicant's birth______________________________

16. When did applicant first leave India___________

17. When was he/she in India last________

18. How long has applicant continuously resided abroad ______________________________

19.(a) PRESENT IMMIGRATION STATUS *ECR/ECNR**_______ (Please attach documentary evidence, such as copy of degree/green card)

*Emigration clearance required **Emigration clearance not required

(b) Educational qualification (in order to determine emigration status)_________________

20. PERMANENT ADDRESS IN INDIA ______________________________________

_______________________________________________________________________

21. (a) ADDRESS IN USA _______________________________TEL._______________

(b) ALIEN REGISTRATION CARD (GREEN CARD), EMPLOYMENT AUTHORIZATION CARD NO.

_________________________________________ (Please attach a photocopy)

22. (a) Name of applicant's eldest son or daughter( First child)________________________

(b) Name of applicant's eldest brother or sister __________________________________

23. Particulars of children, if any to be endorsed in the passport

Note: If name(s) of Child/Children are already included in the present passport, no birth certificate(s) need to be submitted. If this is a fresh passport, please see serial no.7 and 9 of the instruction on reverse.

24. Particulars of two relatives/friends to be intimated in the event of death/accident:

25. Are you a citizen of India by birth/ descent/Naturalization/Registration?_______________

26. Did you ever possess any other nationality or travel document of any other country, if so , please give details __________________________________________________________

____________________________________________________________________

27. Is this application for a : (PLEASE CHECK APPROPRIATE BOX)

28. If this application is for a duplicate passport, was the previous passport Lost OR Damaged _______________ (If damaged, please attach damaged passport)

29. PRESENT PASSPORT NO. / DAMAGED or LOST PASSPORT NO. _____________ Date of issue___________ Place of Issue____________ Date of Expiry__________

(THESE DETAILS MUST BE PROVIDED OTHERWISE APPLICATION WILL REMAIN UNPROCESSED)

30. Were you ever refused a passport? (Yes/No)______. Was your passport ever ordered to be impounded or revoked? (Yes/No)_____. If answer to any of these question is "YES", please enclose a copy of the official communication received by you and give other details___________________________________________________

31. Local Driver's license No. __________________ Date & Place of issue______________

I. D. No.____________________________Date & Place of issue_______________

32. Is applicant in Govt. service/ public undertaking service/statutory bodies service of India?____________. If so, please give details and enclose "No Objection Certificate" from your employer in original. _____________________________________________________________

33. (a) Are any criminal proceedings pending against applicant in any court in India? If so, please give details __________________________________________________________

(b)Has applicant ever been repatriated from abroad to India at the expense of Govt. of India? If so, please give details _______________________________________________________

34. (a) Briefly state circumstances of loss/ theft/ damage of passport and attach report lodged with the local police in case of loss of passport (Please attach your explanation on a separate sheet of paper) ____________________________________________________________

(b) Details of restrictions, if any, put on applicant's damaged/lost passport_______________

(c) Did applicant avail of transfer of residence, foreign travel scheme facility on lost/damaged passport? If so, please give details _____________________________________________

35. Is applicant registered with Indian Mission/Post? If not, is he a member of any Indian organization?___________________________________________________________________

36. DECLARATION :-

I solemnly affirm that

(i) I owe allegiance to the sovereignty and integrity of India, and

(ii) Information given above in respect of myself, my son/daughter/ward is correct and nothing has been concealed and I am aware that it is an offence under the Passport Act 1967 to knowingly furnish false information or suppress material information, which attract penal and other punishments under the acts.

(iii) I undertake to be entirely responsible for expenses of my son/daughter/ ward.

(iv) I have not lost, surrendered or been deprived of my citizenship of India. I have not voluntarily acquired the citizenship of another country.

(v) The information furnished by me in this form is correct.

Place : New York _                          Date ______________ 

(Signature or thumb impression of applicant or his/her legal guardian)

Date : _____________  (Left thumb impression of male and right thumb impression of female)

SPECIMEN SIGNATURES OF APPLICANT

(APPLICATION WILL REMAIN UNPROCESSED WITHOUT APPLICANT'S SPECIMEN SIGNATURES)

PLEASE SUBMIT THE FOLLOWING :

• AFFIDAVIT, DULY NOTARIZED

• INDIAN PASSPORT INDEX CARD