HAJ COMMITTEE OF INDIA
(Constituted under the Act of Parliament No. 35 of 2002)
APPLICATION FORM FOR HAJ-1433 (H)-2012
1. Applied For :
General Category  Reserved Category 
(a).70+ Category (Give Details of Companion): (Please refer Guidlines and Instructions)
Companion Full Name     
Relationship                     
(b) Fourth Time Applicants (Give rejected Cover numbers of last 3 year):
 Year-2009-CoverNo      Year-2010-CoverNo          Year-2011-CoverNo
2. NAME OF THE HEAD OF THE COVER (MALE ONLY):
 
3. ACCOMMODATION STATUS :
GREEN    AZIZIA 
 
4. APPLICANT BIO DATA  (AS PER INTERNATIONAL PASSPORT)
Details of International Passport.  
Passport Number     Place of Issue
Date of Issue Pick a date pick a date.. Date of Expiry  Pick a date pick a date..
If applied for International passport  
Regional Passport Office, File No. Date  Pick a date pick a date..
Applicant:-  
Surname Given Name
Father Name  
Mother Name Spouse Name
Present Residential Address, Including Street No. with PIN code  
PIN CODE
District State
(i) Mobile No. - (ii) Mobile No.-
Tel No.-  
SEX :-       Male  Female  Nationality – INDIAN
Occupation :- MARITAL STATUS Merried  Unmarried 
Identification Mark :- EDU. QUALI :-
Date of Birth Pick a date pick a date.. Age :-
Place of Birth    
   
5. NAME & RELATION OF NOMINEE OR LEGAL REPRESENTATIVE OF APPLICANT:-
   
Full Name Relationship
Address Telephone/ Mobile No.
 
6. NAME OF MEHRAM WITH RELATION (for female pilgrims only)
Full Name Relationship
International Passport No./ File No. of Mehram    
 
7. DETAILS REQUIRED FOR REFUND, IF ANY
Name of the Bank Branch code
Account No. IFS Code
Name of the Branch MICR Code
 
8. Details of non refundable processing fee RS.200/- per pilgrim deposited in Haj Committee of India Account No.31634038682 in any State Bank of India branch.
Amount Name of Branch
Branch Code No. Receipt Date Pick a date pick a date..
 
9. MEEQAT FOR SHIA PILGRIMS:- JOHFA Yes  No