Application for Issue of an Emergency Certificate

2

EA(P) – 4

(2 pages)

GOVERNMENT OF INDIA

MINISTRY OF EXTERNAL AFFAIRS

APPLICATION FOR ISSUE OF AN EMERGENCY CERTIFICATE

NOTES:-

a) Please fill the form in Block letters.

b) This application must be accompanied by four copies of photographs of size 45mm x 35 mm showing frontal view of full face against light background with name on the back of all copies and duly attested by Consular Officer of the Indian Mission.

c) Please do not mark front of photographs in any way of or furnish photographs with

coloured glasses.

d) Paid SR ______Date ______

I PERSONAL PARTICULARS:

1) a) Full name (expanded initials) ______

(in capital letters)

b) Aliases, if any ______

2) Maiden name in case of a married women/widow/divorcees (expanded initials)

a)  Date of Birth: ______

b)  Place of Birth: ______

Village/Town District State Pin code:

3) a) Father's name in full ______

(expanded initials)

b) Mother's name in full ______

(expanded initials)

c) Spouse's (husband/wife) name in full ______

(expanded initials)

4) Profession ______

5) Permanent address in India ______

House No/Street______Police Station ______

Village/Town ______District ______

P.O. ______State ______

6) NATIONALITY :

7) a) Height ______/m ______cms

b) Colour of eyes 1) Black 2) Brown 3) Green 4) Other(Specify)

c) Colour of hair 1) Black 2) Brown 3) Grey 4) Whilte 5)Other(specify)

d) Visible distinguishing marks ______

II Particulars of the Passport/travel documents previously held :

Did you ever hold a passport/travel document ?

Please tick : (1) Yes (2) No

If so, please furnish below the following particulars :

Passport No:______Date of Issue ______

Place of issue ______Date of Expiry ______

If previous passport/travel document is not attached, give reasons for not

doing so ______

Details of any other travel documents ______

III Reasons for applying for an Emergency Certificate ______

______

IV Please indicate whether you are returning to India at

(a) Your own cost (b) the Government of India's cost, OR

(c) the Foreign Government's cost ______

V Declaration of applicant :

I Solemnly declare that

(a) I am a Citizen of India / person of Indian origin

(b) I have not voluntarily acquired citizenship of another country

(c) The information given by me in reply to the question in this form is

true. (If in possession of Citizenship of any other country involuntarily,

please give details ) ______

Place :______

Date : ______

Signature or thumb impression.

Please give two specimen signatures and

Three thumb impressions in the space below for whom the

Emergency Certificate is required :

SIGNATURE THUMB IMPRESSIONS

1)

2)

3)