VISA APPLICATION FORM

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1 VISA APPLICATION FORM EMBASSY OF INDIA TWO PHOTOS HERE PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING THE APPLICATION (PLEASE PRINT IN BLOCK LETTERS ONLY) FOR OFFICE USE ONLY 1. FULL NAME: (First) (Middle) (Last) 2. LAST NAME AT BIRTH (IF DIFFERENT): 3. MARITAL STATUS: Married 4. IF MARRIED GIVE MAIDEN NAME: Unmarried Spouses's Nationality: Spouse's Place of Birth: 5. DATE OF BIRTH 6. SEX: / / mm dd yyyy Male 7. PLACE OF BIRTH (CITY, STATE & COUNTRY): Female 8. CURRENT NATIONALITY: 9. ARE YOU A PERMANENT/LONG-TERM RESIDENT IN USA? Yes No If yes, please furnish photocopy of your GREEN-CARD/Long-term Visa status: (For Non-US passport holders only) 10. NATIONALITY AT BIRTH: 11. ANY OTHER NATIONALITY HELD AT PRESENT/PAST: 12: PRESENT ADDRESS: 13. PHONE: (HOME) (WORK) 14. PERMANENT ADDRESS: 15. PROFESSION: 16. EMPLOYER S NAME AND ADDRESS: 17. PASSPORT NUMBER: 18. VALID UNTIL: 19. ISSUED AT: 20. ISSUE DATE: 21. FATHER S/HUSBAND S NAME: 22. NATIONALITY OF FATHER/HUSBAND: Father's Place Of Birth (State & Country) PAGE 1 OF 2

2 23. NAME AND NATIONALITY OF MOTHER: Mother's Place of Birth (State & Country): 24. TYPE OF VISA REQUIRED (please circle): Tourist l Business l Student l Entry l Transit l Journalist l Conference l Employment l Others l 25. PERIOD OF VISA: 15 Days* l Six Months l One Year l Five Year l Ten Years l (*For Transit only) 26. HAVE YOU EVER VISITED INDIA BEFORE? If yes, give address where you stayed with dates or years: Previous Visa # 27. HAS INDIAN VISA OR EXTENSION OF THE SAME EVER BEEN REFUSED TO YOU PREVIOUSLY? 28. ARE YOU HOLDING A VALID NO OBJECTION TO RETURN TO INDIA ENDORSEMENT? 29. OBJECT OF JOURNEY: Date of Issue: 30. ARE YOU TRAVELLING ON BEHALF OF A COMPANY? Yes No 31. IF YES, GIVE NAME AND ADDRESS OF COMPANY: 32. EXPECTED DATE OF DEPARTURE FROM USA: 33. EXPECTED DATE OF ARRIVAL IN INDIA: 34. PORT OF ARRIVAL IN INDIA: 35. ARE ANY CHILDREN IN YOUR PASSPORT ACCOMPANYING YOU? Full Name Date of Birth Sex (a) (b) 36. NAME AND ADDRESS OF TWO REFERENCES: (a) In India: (b) In applicant s country: I, hereby undertake that I shall utilize my visit to India for the purpose for which the visa has been applied for and shall not, on arrival in India, try to obtain employment or set up business or extend my stay for any other purpose. Signature of applicant: Place: Date: List countries visited in the last 2-3 years: PAGE 2 OF 2

3 ADDITIONAL PARTICULARS FORM (FOR VISA / OCI / PIO CARD SERVICES) *Kindly Note - The form needs to be filled up completely. If anything particular is Not Applicable they need to state (N/A) in the fields. The form cannot be incomplete and must be completed fully. 1. Name of Applicant: 2. Passport Number: Nationality: 3. Please specify whether holding dual nationality. Name of Countries: Passport Numbers: 4. Any previous Nationality held? If yes, specify: 5. Name of Spouse: Current Nationality: 6. Any other Nationality previously held by spouse. Name of Countries: Passport Numbers: 7. Has the applicant ever changed his / her name? If yes, specify details and submit appropriate documentation for the same: 8 Did the applicant or his/her parents or his/her grandparents ever hold the citizenship of Pakistan, Bangladesh, Afghanistan, Bhutan, China, Nepal or Sri Lanka at any point of time? details:

4 9 Did the applicant work before or is currently working w it h Armed Forces / Police / Para-Military Forces / Government service. Name of Organization: Designation: Place of Posting: Rank: 10 Did the applicant ever hold official / diplomatic passport? 11 Current Employment status along with full details of employer: 12 Has the applicant been convicted for any criminal offense or is currently facing criminal charges in any court of law? 13 Has the applicant ever applied for asylum? For applications sent to Washington jurisdiction: 1. All additional particulars form should have signatures of the applicant. 2. When applying for a minor both parents should sign on the on the additional particulars form.

5 DECLARATION I hereby declare that the above particulars are true. I also agree that in case any false information is given in the above form, appropriate action as per Government of India rules and regulations may be taken against me, including but not limited to revoking of issued Visa/OCI/PIO card and any other action as deemed fit by the Government of India or its agencies. I am applying for a PIO card (select whichever not applicable) (a) As a spouse of an Indian origin person (b) Not as a spouse of Indian origin person. In case of (a), I undertake to intimate the Consulate immediately about the dissolution of such marriage, if it occurs. Date: Place: (Signature of the Applicant) Please note: In case of minor child, both parents / legal guardian should sign the declaration

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