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EMBASSY OF CHILE Consular Section New Delhi. Place for Colour Photograph (To be pasted) APPLICATION FORM FOR VISA TO CHILE (To be only typed in Block Letters) 1. LAST NAME(As shown on your Passport) 3. OTHER NAMES: 4. 2. FIRST AND MIDDLE NAME (As shown on your passport) LAST NAME/NAME OF FATHER 5. 6. SEX: M. F. LAST NAME/NAME OF MOTHER 7. DATE OF BIRTH (Day/month/year) 8. PLACE OF BIRTH (City, Province, Country) 9. LOCAL DOCUMENT TYPE AND Nº: 10. NATIONALITY Current Origin 11. HOME ADDRESS 12. HOME TELEPHONE Nº 13. PROFESSION: 14. MARITAL STATUS 15. ACTIVITY 16. EMPLOYER: 17. BUSINESS TELEPHONE Nº 18. COLOR OF HAIR 19. COLOR OF EYES 20. COMPLEXION 21. HEIGHT 23. PASSPORT Nº/TRAVEL DOCUMENT 24. PLACE AND DATE OF ISSUANCE 26. TYPE OF VISA 27. REASON OF TRAVEL 22 .PARTICULAR FEATURES 25. EXPIRATION DATE 28. LENGTH OF PERMANENCE 29. PARTICULARS OF HOST (Name/Last Name – Address and Phone Nº) 30. ARRIVAL DATE 31. ADDRESS IN CHILE (Lodging place) 32. DEPARTURE DATE 33. SPOUSE (Last name, names, nationality, date of birth) 34. CHILDREN (Last name, names, nationality, date of birth) 35. HAVE YOU APPLIED FOR VISA BEFORE? 38. DID YOU ENTER? YES/ NO 39. WHEN? YES YEAR NO 36. WHEN?: YEAR 40. LENGTH OF PERMANENCE 37. WHERE? 41. REASON 42. IS ANY OF THE FOLLOWING PEOPLE IN CHILE? Spouse Fiancé/Fiancée Brothers/Sisters Father/Mother other 43. LIST THE COUNTRIES WHERE YOU HAVE LIVED FOR MORE THAN SIX MONTHS ALONG THE LAST 5 YEARS, COMMENCING FROM YOUR CURRENT RESIDENCE. AFFIDAVIT: I declare that I am aware that during my stay in Chile I may not carry out gainful activities nor intervene in its internal policy or in acts against its Political Constitution or the Laws, Decrees and other provisions applicable in its territory and promise, during my stay in Chile NOT to apply for a change of my status of tourist. I further declare that all the particulars contained in this Application are true. -------------------------------------------DATE --------------------------------------------APPLICANT'S SIGNATURE AUTHORITY LETTER (POWER OF ATTORNEY) To The Consul of Chile in New Delhi Embassy of Chile 146 Jor Bagh, New Delhi-3 Dear Sir, By this act, on this day. …(please indicate here the date), of the year 2007, I, the undersigned Mr./Ms……(name of the applicant), Indian National, holding Passport Number….. valid upto …….., hereby authorize Mr./Ms*…(please indicate the name, organization where he/she is employed, passport number or identity card number or similar documents of the person being authorized), to submit the visa application along with all relevant documents at the Consular Section of the Embassy of Chile in New Delhi. Mr./Ms*/……. (please indicate here again the name of the person being authorized) is also authorized to sign the “Cedula Consular Para Turistas” (a document which forms part of the visa) and to receive the passport duly stamped with visa. (Name and signature of the applicant) (Passport size photograph of applicant to be pasted here and then to be duly attested by the notary) Name & Signature of the Notary Public with official seal