SAMPLE VISA FORM
  

1. Full Name:

John

-

Nyamvumba

First

Middle

Last

2. Last name at birth (if different):

Mack

3. Marital Status:

Married   Unmarried

4. If married give Maiden name:

NA

5. Date of birth:

DD:29 MM:01 YY:1978

6. Sex:

Male Female

7. Place of birth:

Kigali                              Rwanda

City           State               Country

8. Current nationality: 

Rawanda

9. Are you a permanent/long term resident of this  country? 

Yes No

If Yes please furnish your Green-Card/ Long-Term Visa Status: (For non US passport holders only)

NA

10. Nationality at birth:

Rawandese

11. Any other nationality held at present:

No

12. Present Address:

P.O. Box: 3812
Kigali
Rwanda

13. Phone:

Home:82435/78685  Work: NA

14. Permanent address:

DO

15. Profession: 

Student

16. Employer's name and address:

NA

17. Passport No. :

987654321

18. Valid till:

DD:21 MM:02 YY:2006

19. Issued at:

Rawanda

20. Issue date:

DD:21 MM:02 YY:1996

21. Father's/ Husband's Name:

Augustine Nyamvumba

22. Nationality of Father/ Husband:

Rawandese

23. Name and nationality of Mother:

Mary Nyamvumba

24. Type of visa required:

Student Tourist Business Entry Transit Journalist Other

25. Period of visa: 

15 Days* (for transit only) Six months One year Five years

26. Have you ever visited India before? If yes, give addresses where you stayed with dates:

No

27. Has Indian visa or extension of same ever been refused to you previously? 

Yes No

If yes, give details:

NA

28. Are you holding a valid "No objection to return to India" endorsement? 

Yes No

If yes, give details:

NA

29. Object of Journey:

Study

30. Are you traveling on behalf of the company?

Yes No

31. If yes, give name and address of company?

NA

32. Expected date of departure

DD MM YY

33. Expected date of arrival in India?

DD MM YY

34. Port of arrival in India?

New Delhi

35. Are any children included in your passport accompanying you?

Yes No

If yes, give details:

Full Name: NA

 

Date of Birth: NA

 

Sex: NA

36. Name and addresses of two references: 

 

(a) In India:

A.G. Nyamvumba
172, Sector 5, Part VI,
Gurgaon-122001.

(b) In applicants country: 

S.C. Naymvumba
P.O. Box -3789
Kigali - Rawanda

I, John Nyamvumba, 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.

Signature of applicant:_________________________________________________________________

Place: Kigali                                                      Date: DD:14 MM:05 YY:1998