Fill and Sign the Provider Invoice Hfs Hfs Illinois Form

CONSULATE GENERAL OF INDIA 3 EAST 64T H ST REET (Bet. Madison and Fifth Avenue) NEW YORK, NY 10021 T EL (212) 774-0600. Fax (212) 570-9581 E-mail: visa@indiacgny.org For more information visit our w ebsite: P AST E ONE P ASSP ORT SIZE P HOT OGRAP H HERE P lease sign in the box below www.indiacgny.org . VISA APPLICATION FORM !" PLEASE READ INSTRUCTIONS before filling up this form. Instructions can be obtained from the Consulate General of India, New York or from our web site. !" Applications are accepted from 9.15 A.M. to 12:15 P.M. on working days and serviced passports are delivered between 4:30 to 5:15 P.M. !" VALIDITY OF VISA STARTS FROM THE DATE OF ISSUE. This form is also for transfer of visa . !" Enclose passport in Original valid for a minimum of six months !" Send exact amount of FEE in the form of MONEY ORDER/CERTIFIED CHECK payable to CONSULATE GENERAL OF INDIA or in CASH in bills no larger than $50/-. WE DO NOT ACCEPT PERSONAL CHECKS. Use only one mode of payment for the entire fee. !" Please DO NOT SEND CASH IF APPLYING by mail. Also enclose payments (US $ 5 for certified mail or US $ 15 for Express mail) for return of serviced documents by mail. !" Effective 1 February, 2003.This f orm is t o be used by all applicant s residing in t he f ollowing states: CT, ME, MA, NH, NJ, NY, OH, PA, PR, RI, VT, USVI 1. Full Name:________________________________________________________________________________ (First) (Middle ) (Last) 2. Last Name at Birth (if different):___________________________________________________________ 3. Marital Status: Married Unmarried 4. If married, give maiden name:_____________________________________________________________ 5. Date of Birth:___________________ 6. Sex: Male 7. Place of birth:___________________ 8. Current Nationality:_______________________________ mm/dd/yyyy 9. Are you a permanent/long-term resident in USA? Female Yes No If yes, please attach copy of Green Card/Long-Term Visa (Non-US passport holders only) 10. Nationality at birth:_____________________________________________________________________ 11. Any other nationality held at present or in the past:______________________________________ (Are you in possession of any other passport?) 12. Present Address:________________________________________________________________________ _________________________________________________________________________________________ 13. Phone:________________________________(Home) ____________________________________(Work) 14. Permanent Address:____________________________________________________________________ _________________________________________________________________________________________ 15. Profession:______________________________________________________________________________ 16. Employer’s Name and Address:__________________________________________________________ _________________________________________________________________________________________ 17. Passport Number:__________________________ 18. Valid Till:_______________________________ 19. Issued At:________________________________ 20. Issue Date: _____________________________ 21. Name & Nationality of Father: ____________ ____________________________________________ 22. Name & Nationality of Spouse:_________________________________________________________ 23. Name & Nationality of Mother:_________________________________________________________ 24. Type of Visa required: Tourist, Business, Student, Entry, Transfer Transit (for short stopover when traveling to a 3rd country), Journalist, O ther Period of Visa: Days (for Transit with confirmed onward ticket only), Six Months, O ne year, Five years (for persons of Indian origin only, 6 months each visit/Continuous stay), Ten years (for U.S. Citizens only). 25. Have you ever visited India before? If yes, give address and dates of your stay: _______________________________________________________________________________________ ________________________________________________________________________________________ 26. Has Indian visa or its extension of ever been 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 (for foreigners resident in India only): ________________________________________________________________________________________ 29. Purpose of Journey:_____________________________________________________________________ 30. Are you traveling 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 included in your passport accompanying you? Yes No If yes, give details: Full name Date of Birth Sex (a) __________________________________________________________________________________________ (b) __________________________________________________________________________________________ 36. Name and address of references: (a) In India:_________________________________________________________________________________ _____________________________________________________________________________________________ (b) In applicant’s country:___________________________________________________________________ _____________________________________________________________________________________________ I, _____________________________________________________________, (name of the applicant) 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. Date:__________________ Place:____________________ _________________________________ Signature of applicant (parent can sign for minors) (UNSIGNED APPLICATION M AY REM AIN UNPROCESSED)