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:
Whether holds dual nationality,
iif
(If so, both the nationalities to
(if
beso
clearly mentioned)
7. PRESENT ADDRESS IN USA
Telephone No. __________________ Email: _________________________________________
8. COMPLETE PERMANENT ADDRESS IN INDIA:
9. DETAILS OF PASSPORT:
10.
11.
12.
13.
14.
PASSPORT NO:
PLACE OF ISSUE:
VISBILE DISTINGUISHING MARKS IF ANY:
DATE OF LEAVING INDIA:
PERIOD OF STAY ABROAD:
DATE OF LOSS OF PASSPORT:
NAME & ADDRESS OF TWO
(1)
RELATIVES / FRIENDS (AT THE
PLACE OF PERMANENT RESIDENCE IN
_ DATE OF ISSUE:
DATE OF EXPIRY:
(2)
INDIA, Given In Sr.8 Above, Not of the same
family)
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.
_________________________
(Signature)