File Number (For Office Use Only)

GOVERNMENT OF INDIA, MINISTRY OF EXTERNAL AFFAIRS
SUPPLEMENTARY 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
1. Alias Name Details (If you are also known by any other names)
Surname
1.1 Alias Name1, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed)
Surname
1.2 Alias Name2, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed)
2. Previous Name Details (If you have ever changed your name)
Surname
2.1 Previous Name1, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed)
Surname
2.2 Previous Name2, Given Name (Given Name means First Name followed by Middle Name (If any))(Initials not allowed)
3. Previous Residence with Reference Details (Maximum two residences of longest period of stay)
3.1 Previous Residence1
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To (MM-YYYY)
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From (MM-YYYY)
PIN
Police Station
State/ UT
House No. and Street Name
Village or Town or City
District
Mobile Number Telephone Number
Country
First Reference Name and Address
Second Reference Name and Address
Telephone Number
Mobile Number
3.2 Previous Residence2
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To (MM-YYYY)
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From (MM-YYYY)
House No. and Street Name
Village or Town or City
Telephone Number
Mobile Number
Police Station
State/ UT
District
Country
PIN
Mobile Number Telephone Number
First Reference Name and Address
Telephone Number
Mobile Number
Second Reference Name and Address
Telephone Number
Mobile Number
House No. and Street Name
Village or Town or City
Police Station
District
4. Permanent Residential Address (If it is different from present residential address)
State/ UT
Country
PIN
Mobile Number Telephone Number
House No. and Street Name
5. Present Residential Address (If you are on a temporary visit to India)
Village or Town or City
District/ County
State/ Province
Country
PIN
Mobile Number Telephone Number
E-mail ID
6. Diplomatic/ Official Passport Details
Place of Issue
Date of Expiry (DD-MM-YYYY)
Date of Issue (DD-MM-YYYY)
Passport Number
7. Other Details
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Case/ FIR/ Warrant Number
Name of Court and Place
7.1 Provide the following details if there are any criminal proceedings/ warrant pending against you and attach written permission from competent court.
Law and Section(s)
7.2 Provide details if you have ever been convicted by a Court of Law in India and attach copy of judgement
Name of Court and Place
Case/ FIR/ Warrant Number
Law and Section(s)
7.3 Reason for refusal or denial of passport
Reason for impounding/ revocation
7.4 Impounded/ Revoked Passport Details
Passport Number
7.5 Name of the country if ever applied for/ been granted political asylum to/ by any foreign country
7.6 Emergency Certificate Details
Page 7 of 7
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)
Date of Issue (DD-MM-YYYY) (Give MM-YYYY in case cannot recall the exact date)
Reason for deportation/ repatriation
Country from where deported/ repatriated
Issuing Authority
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EC No.