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11. Self Declaration
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
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.
Place
Date (DD-MM-YYYY)
Signature/ Left Hand
Thumb Impression of
Applicant (If applicant is
minor, either parent to
sign)
Branch
10. Enclosures
1.
2.
3.
4.
6.
7.
8.
9.
10.
DD Expiry Date
Bank Name
9. Fee Details (Not to be filled by applicants submitting the application at Passport Seva Kendra)
9.2 If paid by Demand Draft (DD), provide the following details9.1 Fee amount in (Rs)
DD Number
DD Issue Date
8.6 Have you ever returned to India on Emergency Certificate (EC) or were ever deported
or repatriated?
If yes, provide details in Column 7.6 of Supplementary Form
8.5 Have you ever applied for/ been granted political asylum to/ by any foreign country?
If yes, provide details in Column 7.5 of Supplementary Form
8.4 Has your Passport ever been Impounded or Revoked?
If yes, provide details in Column 7.4 of Supplementary Form
8.3 Have you ever been refused or denied passport?
If yes, give reason for refusal or denial of Passport in Column 7.3 of Supplementary
Form
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
8.2 Have you at any time during the period of 5 years immediately preceding the date of
this application been convicted by a court in India for any criminal offence & sentenced
to imprisonment for two years or more?
If yes, fill Column 7.2 of Supplementary Form
5.
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