1. File Number (For Office Use Only)
Service Required
Application Reference Number 14-1002921163
Applying For REISSUE
If Reissue, specify reason(s)
VALIDITY EXPIRED MORE THAN 3
YEARS AGO
Type of Application TATKAAL
Type of Passport Booklet JUMBO
Validity Required NA
Applicant Details
Applicant's Name ANGUVADIVEL RATHINAM
Date of Birth (DD/MM/YYYY) 20/02/1979
Place of Birth (Village/Town/City) KANNARPALAYAM
District COIMBATORE RURAL
State/UT TAMIL NADU
Country INDIA
Gender MALE
Marital Status MARRIED
Citizenship of India by BIRTH
Employment Type PRIVATE
Is either of your parent (in case of
minor)/spouse, a government servant?
N
Educational Qualification 10TH PASS AND ABOVE
Are you eligible for Non-ECR category? N
Visible Distinguishing Mark MOLE BELOW THE RIGHT EYE
Aadhaar Number 481147811660
GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS
PASSPORT APPLICATION FORM
Please read the Passport Instruction Booklet carefully before filling the form. Fill this form in CAPITAL LETTERS using
blue/black ink ball point pen only. Furnishing of incorrect information/ suppression of information would lead to rejection of the
application and would attract penal provisions as prescribed under the Passports Act, 1967. Please produce your original
documents at the time of submission of the form.
Signature/Left Hand Thumb Impression
of Illiterate Applicant and Minors who
cannot sign.
Family Details
Father's Name RATHINAM
Mother's Name MARAGATAM
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2. Spouse's Name POONKODI
Present Address Details
Residing Since(MM/YYYY) 08/2000
Address
16A THENDRAL NAGAR, VEERAKERALAM, COIMBATORE,
VADAVALLI, COIMBATORE, TAMIL NADU
PIN 641007
Mobile/Tel No 9788823525
E-mail VSAI26.12.09@GMAIL.COM
First Reference Name And Address
A.GANESAN,S/O R.ARUSWAMY,14/28 LAKSHMI KOIL
STREET,POOCHIYUR,NARASIMMANAICKEN
PALAYAM,COIMBATORE 6410341
Mobile/Tel No 9578888455
Second Reference Name And Address
G.JAYAKUMAR,S/O GANESAN,91/8 SIVATHANGAM
NAGAR,SAKTHI ROAD, KURUMBAPALAYAM,COIMBATORE
641107
Mobile/Tel No 9943119002
Permanent Address
Address
16A THENDRAL NAGAR, VEERAKERALAM, COIMBATORE,
VADAVALLI, COIMBATORE, TAMIL NADU
PIN 641007
Mobile/Tel No 9788823525
Emergency Contact Details
Name and Address
RATHINAM 16A THENDRAL NAGAR VEERAKERALAM
COIMBATORE
Mobile/Tel No 8012960160
Previous Passport/ Application Details
Details of latest held/existing/lost/damaged Ordinary Passport
Passport Number A5171222
Date of Issue 23/03/1998
Date of Expiry 22/03/2008
Place of Issue CHENNAI
Payment Details
Mode Of Payment Online/Internet Banking
Date 08/04/2014
Receipt/Reference No IGS9139594
Amount Received (Rs.) 2000.00 (TWO THOUSAND ONLY)
Enclosures
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
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3. Self Declaration
I owe allegiance to the sovereignty, unity and 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 COIMBATORE
Date 03/04/2014
Signature/Left Hand Thumb Impression of
Applicant (If applicant is minor, either parent
to sign)
Print Close
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