Fillable Form 5.: ADDITIONAL PARTICULARS FORM FOR RENUNCIATION SERVICES

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Form 5.: ADDITIONAL PARTICULARS FORM FOR RENUNCIATION SERVICES

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ADDITIONAL PARTICULARS FORM FOR RENUNCIATION SERVICES
1.Nameof Applicant:
2.
Passport
Number andNationality :
3.Pleasespecifywhetherholdingdualnationality. :
Ifyes,please
providenameofcountriesand
passport
numbers
4.AnypreviousNationalityheld?Ifyes,specify :
5.
NameofSpouseandcurrentNationality :
6.AnyotherNationalitypreviouslyheldbyspouseIfyes, :
pleaseprovidenameofcountriesand
passport
numbers
7.
Hastheapplicanteverchangedhis/hername?Ifyes, :
specifydetails
and
submit
appropriatedocumentationfor
thesame
8.
Didtheapplicantorhis/herparentsorhis/hergrandparents
:
ever
holdthecitizenshipofBangladesh,Afghanistan,Bhutan,
China,NepalorSriLankaatany
point
oftime?
Ifyes,please
providedetails
9.Whether theapplicantorhis/herparentsorhis/her :
grandp arentseverholdthecitizenshipofPakistan,or
NICOP(NationalIdentityCardforOverseasPakistanis)or
POC(PakistanOriginCard)?Ifyes,specifydetails
10.
DidtheapplicantworkbeforeoriscurrentlyWorkingwith :
ArmedForces/Police/Para-MilitaryForces/Government
service.Ifyes,nameofOrganization,Designation,Place
ofPostingandRankshouldbegiven
11.Didtheapplicanteverholdofficial/diplomaticpassport? :
Ifyes,specifydetails
12. CurrentEmploymentstatusalongwithfulldetailsofemployer :
13. Has the applicant ever been convicted of any criminal offense :
or is currently facing criminal charges in any court of law?
If YES, specify details.
14. Has the applicant or any of his parents ever applied for asylum?:
If yes, specify details
DECLARATION
Iherebydeclarethattheaboveparticularsaretrue. Ialsoagreethatincaseanyfalseinformationisgivenin
theab oveform,appropriateactionasperGovernmentofIndiarulesandregulationsmaybetakenagainstme,includingbut
notlimitedtorevokingofissued Renunciationa ndanyotheractionasdeemedfitbytheGovernmentofIndiaorits
agencies.
IamapplyingforaPIOcard(strikeoffwhichevernotapplicable)-asaspouse
(a)
(b)
ofanIndianoriginperson
not
asaspouseofIndianoriginperson.
Incaseof(a),IundertaketointimatetheConsulateimmediatelyaboutthedissolutionofsuchmarriage,ifitoccurs.
Date:
Place:___________________________
(SignatureoftheApplicant)
Pleasenote:Incaseofmin orchild,bothparents/legalguardianshouldsignthedeclaration
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Form 5.: ADDITIONAL PARTICULARS FORM FOR RENUNCIATION SERVICES

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Completed 8 March 2021

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