ANNEXURE ‘E’
S
PECIMEN DECLARATION OF THE APPLICANT ON A PLAIN PAPER
I
.
.........................
1. That the names of my parents and spouse are as follows:
(i) Father :
(ii) Mother :
(iii) Wife/Husband :
2. That I am a continuous resident at the above mentioned address from ………………………………………..
………………………………………………………………………………………………………………………..
3. That I am a citizen of India by birth/descent/registration/naturalization and that I have neither acquired
the citizenship of another country nor have surrendered or been terminated/ deprived of my citizenshi
p
of India.
4.
That I have not, at any time during the period of five years immediately preceding the date of this
declaration, been convicted by any court in India for any offence involving moral turpitude and sentenced
in respect thereof to imprisonment for not less than two years.
5. That no proceedings in respect of any criminal offence alleged to have been committed by me are pending
before any criminal court in India.
6. That no warrant or summons for my appearance, and no warrant for my arrest, has been issued by a
court under any law for the time being in force, and that my departure from India has not been prohibited
by order of any such court.
7. That I have never been repatriated from abroad back to India at the expense of Government of India/I
was repatriated from abroad back to India at the expense of Government of India, but reimbursed
expenditure incurred in connection with such repatriation.
8. That I will not engage in activities prejudicial to the sovereignty and integrity of India.
9. That my departure from India will not be detrimental to the security of India.
10. That my presence outside India will not prejudice the friendly relations of India with any foreign country.
P
lace: (Signature of applicant)
Date:
I,
residing at
Street/Building Name: Apt or Suite #
City
State
DOB
being an applicant for issue of passport, do hereby solemnly affirm and state the following:
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