FORM EA (P) 4
APPLICATION FOR ISSUE OF AN EMERGENCY CERTIFICATE (EC)

(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

 

Name

Date of birth

Place of birth

Relationship

1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
4. _____________________________________________________________

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