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EMBASSY OF INDIA 2536 Massachusetts Ave. NW Washington, DC 20008 AFFIX ONE PHOTO HERE VISA APPLICATION FORM Visa Application Form for Official/Diplomatic/UN LP Passports only PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING THE APPLICATION 1. FULL NAME: ______________________________________________________________________ (First) (Middle) (Last) 2. LAST NAME AT BIRTH (IF DIFFERENT): 3. MARITAL STATUS: Married_________ Unmarried____________ 4. DATE OF BIRTH 5. SEX _____________________ mm / dd / yyyy 6. PLACE OF BIRTH (CITY, STATE & COUNTRY): Male_______ Female_______ 7. CURRENT NATIONALITY: 8. ARE YOU A PERMANENT/LONG-TERM RESIDENT IN USA? Yes _________ No_________ If yes please furnish photocopy of your GREEN-CARD(both sides)/Long-term Visa Status: ________________________________(For Non-US passport holders only) 9. NATIONALITY AT BIRTH: 10. ANY OTHER NATIONALITY/PASSPORT HELD AT PRESENT OR IN PAST(Give details) 11. PRESENT ADDRESS: 12. PHONE (HOME): (WORK) 13. PERMANENT ADDRESS: 14. PROFESSION: 15. EMPLOYER’S NAME AND ADDRESS: 16. PASSPORT NUMBER: 17. VALID UNTIL: 18. ISSUED AT: 19. ISSUE DATE: 20. FATHER’S/HUSBAND’S NAME: 21. NATIONALITY OF FATHER/HUSBAND: 22. NAME AND NATIONALITY OF MOTHER 23. TYPE OF VISA REQUIRED (please circle): Diplomatic_____ Official_____ UN_____ 24. PERIOD OF VISA: _____ _____ PAGE 1 of 2 25. HAVE YOU EVER VISITED INDIA BEFORE? If yes, give address where you stayed with dates or years: 26. HA INDIAN VISA OR EXTENSION OF THE SAME EVER REFUSED TO YOU PREVIOUSLY ? Yes______ No________ If yes, give details: 27. ARE YOU HOLDING A VALID “NO OBJECTION TO RETURN TO INDIA” ENDORSEMENT? Yes______ No________ If yes, give details: 28. OBJECT OF JOURNEY: 29. ARE YOU TRAVELLING ON BEHALF OF A COMPANY? Yes______ No_______ 30. IF YES, GIVE NAME AND ADDRESS OF COMPANY: 31. EXPECTED DATE OF DEPARTURE FROM USA: (mm/dd/yyyy) 32. EXPECTED DATE OF ARRIVAL IN INDIA: (mm/dd/yyyy) 33. PORT OF ARRIVAL IN INDIA: 34. ARE ANY CHILDREN IN YOUR PASSPORT ACCOMPANYING YOU? Yes______ No______ If yes, give details: Full Name Date of Birth(mm/dd/yyyy) Sex (a) _____________________________________________________________________________________________________________________________________ (b) _____________________________________________________________________________________________________________________________________ 35. 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: ___________________________________ PAGE 2 of 2