VISA APPLICATION FORM - Consulate General of India, Chicago
VISA APPLICATION FORM
NAME :
FATHER’S/HUSBAND’S NAME :
DATE OF BIRTH : PLACE OF BIRTH :
ADDRESS :
TELEPHONE NO. :
PROFESSION : PASSPORT NO. :
DATE OF ISSUE: ______ ISSUED AT: EXPIRY DATE:
CHILDREN INCLUDED IN THE APPLICANT’S PASSPORT (TO BE FILLED IN
ONLY WHEN THE CHILDREN ARE ACCOMPANYING THE APPLICANT)
NAME PLACE AND DATE OF BIRTH IDENTIFICATION MARKS
A.
B.
C.
PRESENT NATIONALITY :
PREVIOUS NATIONALITY : WHETHER VISA
HAS BEEN REFUSED PREVIOUSLY? IF SO, GIVE DETAILS :
DETAILS OF PREVIOUS VISITS TO INDIA :
NO. OF ENTRIES REQUIRED : (SINGLE/DOUBLE/MULTIPLE:
PERIOD OF STAY IN INDIA : PURPOSE OF VISIT:
(TOURIST/VISITOR/BUSINESS/STUDENT/TRANSIT):
PLACES IN INDIA PROPOSED TO BE VISITED :
DATE OF DEPARTURE : PORT OF ENTRY :
DATE OF ARRIVAL IN INDIA :
NAMES AND ADDRESSES OF TWO REFERENCES EACH IN THE COUNTRY OF ORIGIN AND IN INDIA
A. (TEL : )
B. (TEL : )
C. (TEL : )
D. (TEL : )
I, HEREBY UNDERTAKE THAT I SHALL UTILIZE MY VISIT TO INDIA FOR THE PURPOSE FOR WHICH VISA HAS BEEN APPLIED FOR AND SHALL NOT USE IT FOR ANY OTHER PURPOSE. I FULLY UNDERSTAND THAT IF ANY OF THE PARTICULARS FURNISHED ABOVE IS FOUND TO BE INCORRECT OR IF ANY INFORMATION IS FOUND TO HAVE BEEN WITHHELD, THE VISA IS LIABLE TO BE CANCELLED AT ANY TIME.
DECLARATION TO BE MADE BY APPLICANTS SEEKING TO STAY IN INDIA FOR MORE THAN ONE YEAR:
“I HEREBY UNDERTAKE THAT I SHALL SUBJECT MYSELF TO A MEDICAL TEST INCLUDING FOR AIDS WITHIN ONE MONTH OF MY ARRIVAL IN INDIA. IN CASE, I AM FOUND POSITIVE FOR AIDS, I WILL LEAVE INDIA.
(SIGNATURE OF APPLICANT)
RECEIVED PASSPORT :
DATE :
-----------------------
PLEASE
STAPLE TWO
PASSPORT
SIZE
PHOTOGRAPHS
FOR OFFICIAL USE ONLY
VISA NO. & TYPE
D.O.I.
VALIDITY
NO. OF ENTRIES
PERIOD OF STAY
CA COUNS(CONS)
................
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