Passport Application Form (Page 4 of 6) in pdf

Passport Application Form Page 4

19. Self Declaration:

I owe allegiance to the sovereignty, unity & integrity of India, and have not voluntarily

acquired citizenship or travel documents of any other country. I have not lost, surrendered or been deprived

of citizenship of India. The information given by me in this form and enclosures is true and I am solely

responsible for its accuracy. I am aware that it is an offence under the Passports Act, 1967 to furnish any

false information or to suppress any material information with a view to obtaining a passport or any other

travel document.

I further declare that I have no other passport/ travel document.

(Signature/Thumb Impression of Applicant)

Date ………….

(Left Hand Thumb Impression if male and Right

Hand Thumb Impression if female)

Place …………

20. Enclosures:

1 Proof of date of birth .………………………… 2 Proof of Residence …………………………….

3 Educational Qualifications …………………… 4 ……..……..…………………………………….

5 ………………………………………………… 6 …………………………………………….

(For Official Use Only)

Checked by Name

Signature/date

Granted by Name

Signature/date

Scanned by Name

Signature/date

Dispatched by Name

Signature/date

(4)

Passport Application Form Page 4