File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS
PCC 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.
1. Applicant Details
Surname
1.1 Applicant's Given Name (Given Name means First name followed by Middle name (If any))(Initials not allowed)
Place of Issue
Date of Expiry (DD-MM-YYYY)
Date of Issue (DD-MM-YYYY)
Passport Number
Country for which PCC is required
2. Family Details
2.1 Father's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)
Surname
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1.2 Aadhaar Number
2.4 Spouse's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)
2.3 Legal Guardian's Given Name (If applicable) (Initials not allowed)
Surname
Surname
Surname
3. Present Residential Address Details
PIN
Police Station
State/ UT
3.1 House No. and Street Name
Village or Town or City
District
Mobile Number Telephone Number
2.2 Mother's Given Name (Given Name means First name followed by Middle name (If any)) (Initials not allowed)
E-mail ID
3.2 Is permanent address same as present address?
If no, provide details in Column 4 below
No
Yes
4. Permanent Residential Address (If it is different from present residential address)
PIN
Police Station
State/ UT
House No. and Street Name
Village or Town or City
District
Mobile Number Telephone Number
Country
E-mail ID
5. References in your Village or Town or City
5.1 First Reference Name and Address
Page 4 of 4
Telephone Number
Mobile Number
5.2 Second Reference Name and Address
Telephone Number
Mobile Number
6. Other details
Any criminal proceedings pending against you before a court in India? If yes, please attach relevant document.
No
Yes
8. 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)
7. Enclosures
1.
2.
3.
4.
6.
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10.
5.
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