(PLEASE PRINT IN BLOCK LETTERS ONLY)
1. FULL NAME:
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
Female
7. PLACE OF BIRTH (CITY, STATE & COUNTRY):
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:
(First)
(Middle)
(Last)
STAPLE
TWO
PHOTOS
HERE
VISA APPLICATION FORM
mm
dd
yyyy
PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING THE APPLICATION
FOR OFFICE USE ONLY
Note: This application can be used at the Embassy of India, Washington, DC or at any other Consulate
Generals of India provided the applicant resides in states of Consulate’s jurisdiction.
PAGE 1 OF 2
Consulate General of INDIA
455 North City Front Plaza Dr., #850
Chicago, IL 60611
Tel: (312) 595-0405
Fax: (312) 595-0416, 0417
http://chicago.indianconsulate.com
23. NAME AND NATIONALITY OF MOTHER:
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:
27. HAS INDIAN VISA OR EXTENSION OF THE SAME EVER BEEN REFUSED TO YOU PREVIOUSLY?
Yes
No
If yes, give details:
28. ARE YOU HOLDING A VALID “NO OBJECTION TO RETURN TO INDIA” ENDORSEMENT?
Yes
No
If yes, give details:
29. OBJECT OF JOURNEY:
30