HAJ COMMITTEE OF INDIA

ONLINE HAJ APPLICATION FORM FOR HAJ – 1443 (H) – 2022 (C.E.)

2 1 1 1 1 8 3 0 3 0 4 2 2 3 1

1. Category : GENERAL
Embarkation
2. No of Adults Application : 3 COCHIN

3. Name of Cover Head : MOHAMED IBRAHIM

(Male Adult only)

4. Applicant’s Details (As per International Passport)

Passport Number T9847429 Place of Issue CHENNAI

Date of Issue 11-10-2019 Date of Expiry 10-10-2029
Surname ISMAIL Place of Birth ILAYANGUDI
Given Name MOHAMED IBRAHIM Date of Birth 09-04-1978
Father’s Name ISMAIL Gender MALE
Mother’s Name BALKEES BEEVI Spouse’s Name ZUVAIRIYA
Marital Status MARRIED Blood Group B+
Qualification GRADUATE Occupation BUSINESS
Aadhaar No. 210056702962 PAN No.
5. Covid-19 Vaccine Details
Vaccine Covishield Dose 1 Date 02-09-2021
Dose 2 Yes Dose 2 Date 13-12-2021
6. Present Residential Address
Address PLOT NO. X22, 2ND STREET,
THIRUMALAI NAGAR, HASTHINAPURAM Pincode 600064
State TAMIL NADU District KANCHEEPURAM
Mobile Number 9941512365 Email Id
7. Details of Nominee of Applicant
Name KATHER MEERAN
Father’s /Husband’s Name ISMAIL Mobile Number : 9941512399
Relationship BROTHER
Address PLOT NO. X22, 2ND STREET,
Pincode : 600064
State TAMIL NADU District : CHENNAI Signature / Thumb impression of Nominee

8. Name of Mehram with Relation (for female pilgrims only)

Name Relationship :
Passport No.
Signature / Thumb impression of Mehram

9. Bank Account Details

Name of Account Holder MOHAMED IBRAHIM Bank Name INDIAN BANK
Account No. 405340754 IFSC Code IDIB000H017

10. Are you (a) permissible Repeater Mehram ? NO

11. Do you want to perform ADAHI (Qurbani) through IDB ? YES

12. Opting JOHFA Meeqat (only for Shia pilgrims) NO

I do hereby undertake to abide by all the Guidelines including Health Protocol, age and travel restrictions, etc. issued by Kingdom of Saudi Arabia and
Government of India/Haj Committee of India in view of Covid-19 pandemic. I agree to travel by the Embarkation Point allotted to me and ready to pay
all the charges on all accounts. I am also ready to undergo RT-PCR test/Qurantine requirement as per Protocol/Guidelines.
I am aware of the expected increase in the cost of Haj - 2022 due to COVID-19 pandemic situation.
I Certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

All entries in the above online HAF have been checked and found in order. Certified that the applicant is eligible to register for Haj-1443 (H) - 2022 (CE).

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee

 SOLEMN DECLARATION AND UNDERTAKING

for General Category

I,Mr./Mrs./Miss MOHAMED IBRAHIM S/o./W/o./D/o. ISMAIL,Indian citizen, do hereby solemnly declare on oath in the name of ALLAH that :

1) I am aware that as per Government of India’s policy a person can perform Haj only “Once in a life time” through Haj Committee of India.

2) I have never performed Haj through Haj Committee of India in the past and hence I am eligible to apply for Haj-2022, as per Guidelines of Haj-2022. I
am aware that Repeaters are not eligible for Haj-2022 and if it is detected at any stage that I have already performed Haj through Haj Committee of
India, my seat shall be cancelled and the entire amount deposited shall be forfeited.

3) I have read / understood the Guidelines for Haj 1443 (H) – 2022 (C.E.), specifically with regard to Eligibility (para – 4), Cost, Payments and
Confirmation (para – 9), Cancellation (para – 10), Refunds (para – 11) Embarkation Points (para – 12), Vaccination and Health Requirements Before
Flight (para 13) Baggage (para – 15), Flight (para 18), Accommodation in Kingdom of Saudi Arabia (para – 20), and undertake to abide by the same.

4) I authorize Haj Committee of India to procure Saudi Riyals on my behalf for disbursal / remittance to CGI.

5) I hereby authorize HCoI to send SMS on my Mobile Number even if I am registered under DND registry.

6) Particulars given by me in HAF, Solemn Declaration and Undertaking are true and correct to the best of my knowledge. I do hereby affirm and
declare that in case I have suppressed material information or given false / incorrect Declaration / Undertaking, HCoI shall forfeit the amount deposited
by me and I shall be liable for prosecution.

7) I am aware that HCoI reserves the right to change the Embarkation Point opted by me. In such case, I shall be abide by the decision of HCoI and
shall not show any resentment, whatsoever, against the decision of HCoI.

8) I am ready to pay extra charges, as levied by the KSA Haj Authorities for endorsement of Haj visa.

9) I/We understand that Haj Committee of India works without profit motive and does not attract the provisions of Consumer Protection Act, 2019.
Further, we understand that the Courts of Greater Mumbai only shall exercise jurisdiction in all matters of dispute.

10) Haj journey of pilgrims carrying Khash-khash, Viagara-tablets, Sexual oil and cream, Synthetic Capore, Cystone, Khammera, Gutkha, Khaini, Gul,
Pipermint or narcotics in any form shall be cancelled besides he/she will be penalized for carrying band items as per of prevailing regulations of Saudi
Arabia. If found, they will be liable for deportation to India from KSA at any stage of Haj.

Date : _________________________

Place : _________________________

___________________________________________

Signature / Thumb impression of the applicant.

 HAJ COMMITTEE OF INDIA
ONLINE HAJ APPLICATION FORM FOR HAJ – 1443 (H) – 2022 (C.E.)
Pilgrim Detail : 2

1. Category : GENERAL
Embarkation
2. No of Adults Application : 3 COCHIN

3. Name of Cover Head : MOHAMED IBRAHIM

(Male Adult only)

4. Applicant’s Details (As per International Passport)

Passport Number T6245538 Place of Issue CHENNAI

Date of Issue 11-07-2019 Date of Expiry 10-07-2029
Surname MOHAMED MEERA Place of Birth ILAYANGUDI
Given Name BALKEES BEEVI Date of Birth 15-05-1958
Father’s Name MOHAMED MEERA Gender FEMALE
Mother’s Name MARIAM BEEVI Spouse’s Name ISMAIL
Marital Status MARRIED Blood Group B+
Qualification PRIMARY Occupation HOUSE WIFE
Aadhaar No. 895990688108 PAN No.
5. Covid-19 Vaccine Details
Vaccine Covishield Dose 1 Date 02-08-2021
Dose 2 Yes Dose 2 Date 06-11-2021
6. Present Residential Address
Address PLOT NO. X22, 2ND STREET,
THIRUMALAI NAGAR, SEMBAKKAM Pincode 600073
State TAMIL NADU District KANCHEEPURAM
Mobile Number 9941512365 Email Id
7. Details of Nominee of Applicant
Name KATHER MEERAN
Father’s /Husband’s Name ISMAIL Mobile Number : 9941512399
Relationship SON
Address PLOT NO. X22, 2ND STREET,
Pincode : 600064
State TAMIL NADU District : KANCHEEPURAM Signature / Thumb impression of Nominee

8. Name of Mehram with Relation (for female pilgrims only)

Name MOHAMED IBRAHIM Relationship : SON
Passport No. t9847429
Signature / Thumb impression of Mehram

9. Bank Account Details

Name of Account Holder MOHAMED IBRAHIM Bank Name INDIAN BANK
Account No. MOHAMED IBRAHIM IFSC Code IDIB000H017

10. Are you (a) permissible Repeater Mehram ? NO

11. Do you want to perform ADAHI (Qurbani) through IDB ? YES

12. Opting JOHFA Meeqat (only for Shia pilgrims) NO

I do hereby undertake to abide by all the Guidelines including Health Protocol, age and travel restrictions, etc. issued by Kingdom of Saudi Arabia and
Government of India/Haj Committee of India in view of Covid-19 pandemic. I agree to travel by the Embarkation Point allotted to me and ready to pay
all the charges on all accounts. I am also ready to undergo RT-PCR test/Qurantine requirement as per Protocol/Guidelines.
I am aware of the expected increase in the cost of Haj - 2022 due to COVID-19 pandemic situation.
I Certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

All entries in the above online HAF have been checked and found in order. Certified that the applicant is eligible to register for Haj-1443 (H) - 2022 (CE).

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee

 SOLEMN DECLARATION AND UNDERTAKING

for General Category

I,Mr./Mrs./Miss BALKEES BEEVI S/o./W/o./D/o. MOHAMED MEERA,Indian citizen, do hereby solemnly declare on oath in the name of ALLAH that :

1) I am aware that as per Government of India’s policy a person can perform Haj only “Once in a life time” through Haj Committee of India.

2) I have never performed Haj through Haj Committee of India in the past and hence I am eligible to apply for Haj-2022, as per Guidelines of Haj-2022. I
am aware that Repeaters are not eligible for Haj-2022 and if it is detected at any stage that I have already performed Haj through Haj Committee of
India, my seat shall be cancelled and the entire amount deposited shall be forfeited.

3) I have read / understood the Guidelines for Haj 1443 (H) – 2022 (C.E.), specifically with regard to Eligibility (para – 4), Cost, Payments and
Confirmation (para – 9), Cancellation (para – 10), Refunds (para – 11) Embarkation Points (para – 12), Vaccination and Health Requirements Before
Flight (para 13) Baggage (para – 15), Flight (para 18), Accommodation in Kingdom of Saudi Arabia (para – 20), and undertake to abide by the same.

4) I authorize Haj Committee of India to procure Saudi Riyals on my behalf for disbursal / remittance to CGI.

5) I hereby authorize HCoI to send SMS on my Mobile Number even if I am registered under DND registry.

6) Particulars given by me in HAF, Solemn Declaration and Undertaking are true and correct to the best of my knowledge. I do hereby affirm and
declare that in case I have suppressed material information or given false / incorrect Declaration / Undertaking, HCoI shall forfeit the amount deposited
by me and I shall be liable for prosecution.

7) I am aware that HCoI reserves the right to change the Embarkation Point opted by me. In such case, I shall be abide by the decision of HCoI and
shall not show any resentment, whatsoever, against the decision of HCoI.

8) I am ready to pay extra charges, as levied by the KSA Haj Authorities for endorsement of Haj visa.

9) I/We understand that Haj Committee of India works without profit motive and does not attract the provisions of Consumer Protection Act, 2019.
Further, we understand that the Courts of Greater Mumbai only shall exercise jurisdiction in all matters of dispute.

10) Haj journey of pilgrims carrying Khash-khash, Viagara-tablets, Sexual oil and cream, Synthetic Capore, Cystone, Khammera, Gutkha, Khaini, Gul,
Pipermint or narcotics in any form shall be cancelled besides he/she will be penalized for carrying band items as per of prevailing regulations of Saudi
Arabia. If found, they will be liable for deportation to India from KSA at any stage of Haj.

Date : _________________________

Place : _________________________

___________________________________________

Signature / Thumb impression of the applicant.

 HAJ COMMITTEE OF INDIA
ONLINE HAJ APPLICATION FORM FOR HAJ – 1443 (H) – 2022 (C.E.)
Pilgrim Detail : 3

1. Category : GENERAL
Embarkation
2. No of Adults Application : 3 COCHIN

3. Name of Cover Head : MOHAMED IBRAHIM

(Male Adult only)

4. Applicant’s Details (As per International Passport)

Passport Number T9847428 Place of Issue CHENNAI

Date of Issue 11-10-2019 Date of Expiry 10-10-2029
Surname HAYATH Place of Birth CHENNAI
Given Name ZUVAIRIYA Date of Birth 08-11-1981
Father’s Name HAYATH SEVUSU Gender FEMALE
Mother’s Name AISHA Spouse’s Name MOHAMED IBRAHIM
Marital Status MARRIED Blood Group O+
Qualification GRADUATE Occupation HOUSE WIFE
Aadhaar No. 900999968533 PAN No.
5. Covid-19 Vaccine Details
Vaccine Covishield Dose 1 Date 02-09-2021
Dose 2 Yes Dose 2 Date 17-12-2021
6. Present Residential Address
Address PLOT NO. X22, 2ND STREET,
THIRUMALAI NAGAR, HASTHINAPURAM Pincode 600064
State TAMIL NADU District KANCHEEPURAM
Mobile Number 9941512365 Email Id
7. Details of Nominee of Applicant
Name ISMAIL
Father’s /Husband’s Name SIKKANDER Mobile Number : 7299114507
Relationship FATHER IN LAW
Address PLOT NO. X22, 2ND STREET,
Pincode : 600064
State TAMIL NADU District : KANCHEEPURAM Signature / Thumb impression of Nominee

8. Name of Mehram with Relation (for female pilgrims only)

Name MOHAMED IBRAHIM Relationship : HUSBAND
Passport No. t9847429
Signature / Thumb impression of Mehram

9. Bank Account Details

Name of Account Holder MOHAMED IBRAHIM Bank Name INDIAN BANK
Account No. MOHAMED IBRAHIM IFSC Code IDIB000H017

10. Are you (a) permissible Repeater Mehram ? NO

11. Do you want to perform ADAHI (Qurbani) through IDB ? YES

12. Opting JOHFA Meeqat (only for Shia pilgrims) NO

I do hereby undertake to abide by all the Guidelines including Health Protocol, age and travel restrictions, etc. issued by Kingdom of Saudi Arabia and
Government of India/Haj Committee of India in view of Covid-19 pandemic. I agree to travel by the Embarkation Point allotted to me and ready to pay
all the charges on all accounts. I am also ready to undergo RT-PCR test/Qurantine requirement as per Protocol/Guidelines.
I am aware of the expected increase in the cost of Haj - 2022 due to COVID-19 pandemic situation.
I Certify that the information furnished above is true and correct.

Signature / Thumb impression of the Applicant

FOR OFFICE USE ONLY

All entries in the above online HAF have been checked and found in order. Certified that the applicant is eligible to register for Haj-1443 (H) - 2022 (CE).

Online HAF Checked by Verified by Executive Officer, State / UT Haj Committee

 SOLEMN DECLARATION AND UNDERTAKING

for General Category

I,Mr./Mrs./Miss ZUVAIRIYA S/o./W/o./D/o. HAYATH SEVUSU,Indian citizen, do hereby solemnly declare on oath in the name of ALLAH that :

1) I am aware that as per Government of India’s policy a person can perform Haj only “Once in a life time” through Haj Committee of India.

2) I have never performed Haj through Haj Committee of India in the past and hence I am eligible to apply for Haj-2022, as per Guidelines of Haj-2022. I
am aware that Repeaters are not eligible for Haj-2022 and if it is detected at any stage that I have already performed Haj through Haj Committee of
India, my seat shall be cancelled and the entire amount deposited shall be forfeited.

3) I have read / understood the Guidelines for Haj 1443 (H) – 2022 (C.E.), specifically with regard to Eligibility (para – 4), Cost, Payments and
Confirmation (para – 9), Cancellation (para – 10), Refunds (para – 11) Embarkation Points (para – 12), Vaccination and Health Requirements Before
Flight (para 13) Baggage (para – 15), Flight (para 18), Accommodation in Kingdom of Saudi Arabia (para – 20), and undertake to abide by the same.

4) I authorize Haj Committee of India to procure Saudi Riyals on my behalf for disbursal / remittance to CGI.

5) I hereby authorize HCoI to send SMS on my Mobile Number even if I am registered under DND registry.

6) Particulars given by me in HAF, Solemn Declaration and Undertaking are true and correct to the best of my knowledge. I do hereby affirm and
declare that in case I have suppressed material information or given false / incorrect Declaration / Undertaking, HCoI shall forfeit the amount deposited
by me and I shall be liable for prosecution.

7) I am aware that HCoI reserves the right to change the Embarkation Point opted by me. In such case, I shall be abide by the decision of HCoI and
shall not show any resentment, whatsoever, against the decision of HCoI.

8) I am ready to pay extra charges, as levied by the KSA Haj Authorities for endorsement of Haj visa.

9) I/We understand that Haj Committee of India works without profit motive and does not attract the provisions of Consumer Protection Act, 2019.
Further, we understand that the Courts of Greater Mumbai only shall exercise jurisdiction in all matters of dispute.

10) Haj journey of pilgrims carrying Khash-khash, Viagara-tablets, Sexual oil and cream, Synthetic Capore, Cystone, Khammera, Gutkha, Khaini, Gul,
Pipermint or narcotics in any form shall be cancelled besides he/she will be penalized for carrying band items as per of prevailing regulations of Saudi
Arabia. If found, they will be liable for deportation to India from KSA at any stage of Haj.

Date : _________________________

Place : _________________________

___________________________________________

Signature / Thumb impression of the applicant.

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