(This application must be accompanied by three passport size photographs)
| I. | FEE | |||||||||
| 1. | Amount paid | |||||||||
| 2. | Date of payment: | |||||||||
| 3. | Mode of payment: | |||||||||
| II. | PERSONAL PARTICULARS: | |||||||||
| 1. | (a) Full
name: ________________________________________ (in block letters) | |||||||||
| (b) Aliases,
if any: _____________________________________ (in block letters) | ||||||||||
| 2. | Previous names, if you have ever changed your name: ___________________________________________________ | |||||||||
| 3. | Maiden name, in case of married woman/widow/divorcee: ___________________________________________________ | |||||||||
| 4. | Father's name: _______________________________________ | |||||||||
| 5. | Husband's name in case of a married woman/widow/divorcee: ___________________________________________________ | |||||||||
| 6. | Permanent address in India: ___________________________________________________ | |||||||||
| 7. | Present Address abroad: ___________________________________________________ | |||||||||
| 8. | Present National status: ___________________________________________________ | |||||||||
| 9. | Profession: __________________________________________ | |||||||||
| 10. | Place of Birth: ________________________________________ | |||||||||
| 11. | Date of Birth: ________________________________________ | |||||||||
| 12. | Height: _____________________________________________ | |||||||||
| 13. | Colour of eyes: _______________________________________ | |||||||||
| 14. | Colour of hair: ________________________________________ | |||||||||
| 15. | Visible distinguishing marks, if any: ___________________________________________________ | |||||||||
| III. | PARTICULARS OF CHILD/CHILDREN BELOW 15 YEARS OF AGE TO BE INCLUDED IN THE EMERGENCY CERTIFICATE | |||||||||
| ||||||||||
| IV. | PARTICULARS OF THE PASSPORT/TRAVEL DOCUMENT PREVIOUSLY HELD | |||||||||
| 1. | Did you ever
hold a passport/travel
document? _________________________________________________ | |||||||||
| 2. | If so, please furnish the following particulars: | |||||||||
| (a) Number: _______________________________________ | ||||||||||
| (b) Date of issue: ___________________________________ | ||||||||||
| (c) Authority and place of issue: _________________________________________________ | ||||||||||
| N.B. The Passport/travel document, if available, should be submitted together with this application. (photocopy of passport may please be attached). | ||||||||||
| 3. | If not a position to submit the passport/travel document, please indicate the reasons therefor: _________________________________________________ | |||||||||
| V. | REASONS OF APPLYING FOR AN EMERGENCY CERTIFICATE: | |||||||||
| ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ | ||||||||||
| VI. | DECLARATION OF APPLICANT | |||||||||
| I solemnly declare
that: (i) I am citizen of India/person of India origin: _________________ (ii) I have not voluntarily acquired citizenship of another country and (iii) The information given by me in reply to the question in this form is true. | ||||||||||
Place:
____________________________
Date: ____________________________
_________________________________
Signature of thumb
impression
(left in case of a male and right in case of
a female) of the
applicant.
Two specimen
signature of thumb impression (left in case of a male and right in case of a
female) of the applicant.
|
1
|
2 |
If in possesion of
a Citizenship of any other country involuntarily please give details.
_____________________________________________________________________________
_____________________________________________________________________________
TWO SPECIMEN SIGNATURES
|
_____________________________________ |
____________________________________ |