GOVERNMENT OF MANIPUR SECTT: HOME DEPARTMENT APPLICATION FORM FOR PROTECTED AREA PERMIT FOR ENTERING MANIPUR Please append A recent passport size photograph Here 1. Name of the applicant : .......................... (in capital letters with surname underlined) 2. Father's/Husband's name : .......................... 3. Place & date of birth : .......................... 4. Nationality a) Present : .......................... b) Past : .......................... 5. Occupation (indicate also address of : ................................ place of work, if employed) 6. Mailing address in India : ......................... 7. Permanent address : ......................... 8. Reference (a) In country of applicant : ......................... (b) In India : ......................... 9. Passport details : Number : ......................... (to be supported by Xerox copy) ............................... 10. Details of VISA for India, if any obtained : .......................... (to be supported by Xerox copy) No................ issued at......................... 11. Place(s) proposed to be visited : .......................... 12. Route intended to be followed : .......................... 13. Likely date of visit : .......................... 14. Purpose of visit : .......................... 15 Likely duration of visit : .......................... 16. Is anyone accompanying the applicant, if so, give details : .......................... .......................... 17. Arrangements for travel & : accommodation that have been made 18. Details of previous visit to Manipur, if any : 19. Has he/she previously visited : any protected area(s) in Manipur and, if so, please furnish details. 20. Has any earlier request for : permit been refused, if so, give details. Date .......... Place ........... Signature of the applicant Note: 1. This application is to be submitted to the Home Department, Government of Manipur, Imphal-795001. 2. It is advisable to submit the application at least four weeks before the proposed visit.
