FORM EA (P) 4
Application for issue of an Emergency Certificate
(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 a 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.
.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 |
|
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3 |
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4 |
|
|
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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.
3. If not in a position to submit the passport /travel document, please indicate
the reason 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 Indian origin;
(ii) I have not voluntarily acquired citizenship of another country; and
(iii) The information given by me in reply to the questions in this form is true.
Place----------------
Date------------------
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Signature or thumb-impression (left in case of a male and right in case of a female ) of the applicant.
Two specimen signatures or thumb-impression (left in case of a male and right in case of a female) of the applicant.
If in possession of citizenship of-------------------------
any other country In--------------------------
voluntarily please give -------------------------
details.
