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india
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PERFORMA FOR VERIFICATION OF NATIONALITY STATUS/ANTECEDENTS
(PLEASE TYPE OR PRINT)
1. FULL NAME: ____________________________________________________
2. ALIASES, IF ANY: ____________________________________________________
3. (a) FULL NAME OF FATHER: ____________________________________________________
(b) FULL NAME OF MOTHER: ____________________________________________________
(c) FULL NAME OF SPOUSE: ____________________________________________________
4. DATE AND PLACE OF BIRTH: ____________________________________________________
(DD-MM-YYYY) (VILLAGE) (DISTRICT)
5. PRESENT OCCUPATION: ____________________________________________________
6. NATIONALITY: ____________________________________________________
7. PRESENT ADDRESS IN USA ____________________________________________________
____________________________________________________
8. COMPLETE PERMANENT ADDRESS IN INDIA: _______________________________________
____________________________________________________
____________________________________________________
9. DETAILS OF PASSPORT: PASSPORT NO:______________ DATE OF ISSUE: _____________
PLACE OF ISSUE: ____________ DATE OF EXPIRY: ____________
10. VISBILE DISTINGUISHING MARKS IF ANY:_____________________________________________
11. DATE OF LEAVING INDIA: ____________________________________________________
12. PERIOD OF STAY ABROAD: ____________________________________________________
13. DATE OF LOSS OF PASSPORT: ____________________________________________________
14. NAME & ADDRESS OF TWO (1) _________________________________________________
RELATIVES / FRIENDS (AT THE ________________________________________________________________________ PLACE OF PERMANENT RESIDENCE IN (2) _____________________________________________________________________
INDIA, Given In Sr.8 Above) ___________________________________________________
15. NAME & ADDRESS OF TRAVEL ____________________________________________________
AGENT INVOLVED IN SENDING ____________________________________________________
THE INDIVIDUAL ABROAD ____________________________________________________
NOTE: Please Complete all entries Legibly and fully: Incomplete Information will only lead to delay in the process of issuing passport.
Paste one passport size
photograph here (2 X 2)