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1. Visa Application Form
A. Personal Particulars (As in Passport)
Surname (As in Passport)
Given Name (As in Passport)
Previous/other Name if any
Sex Marital Status
Date of birth Religion
Place of Birth Town/City Country of Birth
Citizenship /National ID No Educational Qualification
Visible identification marks
Current Nationality Nationality by Birth/ Naturalization
Any Other Previous/Past Nationality
B. Passport Details
Passport No. Date of issue ( dd/mm/yyyy )
Place of issue Date of expiry (dd/mm/yyyy)
Any other Passport/Identity Certificate held (if yes ,please fill in the following)
Country of issue Place of issue
Passport/IC No Date of issue(dd/mm/yyyy)
Nationality/status
C. Applicant’s Contact Details
Phone No
Mobile /Cell No
Present
address
Email address
Permanent
Address
D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
Father’s
Mother’s
Spouse
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area :
E. Details of Visa Sought (Visa shall be valid from the Date of Issue and not from the Date of Journey)
Type Of Visa Required No of Entries
Period of Visa Expected Date of Journey
Port Of Arrival Port of Exit
Paste your unsigned
recent color photograph.
Size: 2” X 2”
Signature
NLDT04044214
PATTIE ANN PARKINSON VARKEVISSER
HENDRIK IDO AMBACHT
UNITED STATES OF AMERICA
UNITED STATES OF AMERICA
WebFileNumber:NLDT04044214
SAN FRANCISCO
PATTIE ANN
UNITED STATES OF AMERICA
NETHERLANDS
UNITED STATES OF AMERICA
06 37559794
WebRegistrationDate:22-SEP-2014
MUMBAI
MAARTEN VARKEVISSER
20-MAR-2013
456221940
20-MAR-2018
pattivarkevisser@gmail.com
1 Month
UNITED STATES OF AMERICA
PARKINSON VARKEVISSER
THE NETHERLANDS
NATURALIZATION
NO
WHITTIER
HOLLYWOOD
27-JUL-2009
NETHERLANDS
MUMBAI
KATWIJK
NETHERLANDS
UITERWAARD 24
HENDRIK IDO AMBACHT
ZUID HOLLAND
AMSTERDAM
31-DEC-1975
UNITED STATES OF AMERICA
BUITENRUSTWEG 2, 2517 KD ,THE HAGUE
Single
MD PARKINSON
Female
239261185
UNITED STATES OF AMERICA
NXKRJ30L2
Married
NO
078 614 8070
www.indianembassy.nl
YES
(Month)
UNITED STATES OF AMERICA
CD HASH
EMBASSY OF INDIA
16-OCT-2014
TOURIST VISA
HIGHER SECONDARY
HENDRIK IDO AMBACHT
CHRISTIAN
UITERWAARD 24
ZUID HOLLAND, NETHERLANDS 3344ED
0031 70 3469771

2. Required Detail of
Purpose of Visit :
F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years
Have you been refused an Indian Visa or extension of the same previously or deported from India ?
If yes above mention when and by whom with control
No/Date
G. Profession/Occupation Details
Present Occupation Designation/Rank
Employer name/business
Employer Address
Phone Number
Past occupation if any
Are/have you worked with Armed forces/ Police/ Para Military forces ?
Organization Designation
Place of Posting Rank
H. Address of Place of Stay / Hotel
Place/Hotel Name Address of Place / Hotel State Phone No.
I. Details of Two Reference
In India In
Name
Address
Phone
Number
J. DECLARATION:
a. I do not hold any other passport(s) other than those detailed above.
b. I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them.
c. I declare that the information given in the form is complete and correct and the visit to India will be undertaken for the
purpose indicated in the application.
d. I understand that in case the information provided in the form is found to be incorrect, I will be liable for denial of visit/ entry
or deportation and/ or other penalties during the visit as provided by Indian law.
..……………………………………
Date :………………………. Applicant’s signature (as in Passport)
FAM. HAASNOOT
NO
THE HAGUE
NETHERLANDS
US, INDIA, THAILAND, FRANCE, & ITALY
WebFileNumber:NLDT04044214
SALMAN FURNITURE
HOUSE WIFE
SCHIMMELPENNICKSTRAAT 77
08-APR-2014
22-SEP-2014
071 4032937
MANGALAPRUAM,CHENNAI 600012(FRIEND)
7756142
STUDENT
655 GREEN VIEW ROAD, LA HABRA CA USA
31, FIRST STREET, KRISHNADOSS ROAD,
2221KZ KATWIJK
31, FIRST STREET, KRISHNADOSS ROAD,, MANGALAPRUAM, CHENNAI 600012
of Father
H. LAMECH INBARAJ
H. LAMECH INBARAJ
00914426620212
Places to be Visited
562 6915911
YES
TOURISM
CHENNAI & MUMBAI
TOURIST VISA
TOURIST VISA
DELHI, OOTY, CHENNAI