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1. Full Name:
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John
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-
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Nyamvumba
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First
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Middle
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Last
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2. Last name at birth (if different):
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Mack
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3. Marital Status:
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Married
Unmarried
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4. If married give Maiden name:
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NA
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5. Date of birth:
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DD:29
MM:01 YY:1978
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6. Sex:
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Male
Female
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7. Place of birth:
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Kigali Rwanda
City State Country
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8. Current nationality:
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Rawanda
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9. Are you a permanent/long term resident of
this country?
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Yes
No
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If Yes please furnish your Green-Card/ Long-Term
Visa Status: (For non US passport holders only)
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NA
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10. Nationality at birth:
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Rawandese
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11. Any other nationality held at present:
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No
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12. Present Address:
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P.O.
Box: 3812
Kigali
Rwanda
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13. Phone:
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Home:82435/78685
Work: NA
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14. Permanent address:
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DO
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15. Profession:
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Student
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16. Employer's name and address:
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NA
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17. Passport No. :
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987654321
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18. Valid till:
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DD:21
MM:02 YY:2006
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19. Issued at:
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Rawanda
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20. Issue date:
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DD:21
MM:02 YY:1996
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21. Father's/ Husband's Name:
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Augustine
Nyamvumba
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22. Nationality of Father/ Husband:
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Rawandese
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23. Name and nationality of Mother:
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Mary
Nyamvumba
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24. Type of visa required:
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Student
Tourist Business
Entry Transit
Journalist Other
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25. Period of visa:
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15 Days* (for transit only) Six
months One year Five
years
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26. Have you ever visited India before? If yes,
give addresses where you stayed with dates:
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No
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27. Has Indian visa or extension of same ever
been refused to you previously?
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Yes
No
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If yes, give details:
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NA
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28. Are you holding a valid "No objection
to return to India" endorsement?
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Yes
No
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If yes, give details:
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NA
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29. Object of Journey:
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Study
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30. Are you traveling on behalf of the company?
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Yes
No
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31. If yes, give name and address of company?
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NA
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32. Expected date of departure
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DD
MM YY
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33. Expected date of arrival in India?
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