ministry of home affairs-India-an overview Page 1 of 3 Visa Form S. 109-A APPENDIX 1 Para 3(1)(a) PART-A (Visa Application) (TO BE FILLED BY ALL APPLICANTS FOR VISA) 1. (a) Full Name (In Block Letters) Please affix a Passport size Mr./Mrs./Miss._______________________________ photograph here. (b) Surname at birth (if different)______________________ (c) Father's/Husband's Name__________________________ 2. Whether any children accompanying applicant are included in his/her passport. If so give the following details:- 3. Address : http://mha.nic.in/visap.htm 7/26/2006 ministry of home affairs-India-an overview Page 2 of 3 4. Date of Birth 5. Place of Birth 6. Present Nationality 7. Any other nationality, previous or present, with dates 8. Profession or Occupation 9. Particulars of passport or other travel documents: (a) Number________________ (b) Place of Issue______________________ (c) Date of Issue____________ (d) Date of Expiry______________________ 10. Have you visited India previously, if so indicate places with dates____________________ 11. Whether permission to visit India or to extend stay in India has been refused previously, if so, when__________________________________________________ 12.(a) Period for which visa is required_______________________________________ (Note: Extension of Transit Visas which are valid for three days will not generally be granted.) (b) Whether a single, double, triple or multiple entry visa is required__________________ 13. Object of journey a. Transit (Place/country to be visited further) b. Tourism (Places/areas to be visited) c. Business (Trade/Project/Scheme -Brief description to be given) (Party/parties to be contacted) d. Education (Name and particulars of educational institutions) e. Any other http://mha.nic.in/visap.htm 7/26/2006 ministry of home affairs-India-an overview Page 3 of 3 PART-B (NOT TO BE FILLED BY APPLICANTS FOR TOURIST VISAS) 1. Whether holding valid 'No Objection to return endorsement', if so, give particulars____________________________________________________________ 2. State, Town, etc. of destination in India_____________________________________ 3. Port of landing in India__________________________________________________ 4. Name and address of persons who will furnish information as to applicant and also furnish financial guarantees for maintenance and repatriation if referred to :- IN COUNTRY OF APPLICANT (i) (ii) IN INDIA (i) (ii) I, _________________________ hereby undertake that I shall utilise 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___________ Signature_____________________ (Clarification: There may be variations in forms issued by various Indian Missions -specific requirements may be obtained from the concerned Mission by the applicant.) Back http://mha.nic.in/visap.htm 7/26/2006
