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High Commission of India

Menara 1 Mont Kiara, Level 28,


50480 Kuala Lumpur Paste your unsigned
www.indianhighcommission.com.my recent color photograph.
00603-6205 2350 Size: 2 X 2

Visa Application Form

Signature
MYSK10432317

A. Personal Particulars (As in Passport)


Surname (As in Passport) S BALAMURALI
Given Nam e (As in Passport) SREEAKILANDESHWARI
Previous/other Name if any
Sex FEMALE Marital Status SINGLE
Date of birth 13-NOV-2010 Religion HINDU
INDIA INDIA
Application Id :MYSK10432317

Place of Birth Town/City Country of Birth


Citizenship /National ID No 128098 Educational Qualification MATRICULATION
Visible identification marks NIL
Current Nationality MALAYSIA Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. A40025976 Date of issue ( dd/mm/yyyy ) 04-JUL-2017
Place of issue KUALA LUMPUR Date of expiry (dd/mm/yyyy) 04-JUL-2022
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of issue Place of issue
Passport/IC No Date of issue(dd/mm/yyyy)
Web Registration Date : 06-JUL-2017

Nationality/status
C. Applicants Contact Details

BLOCK C 6 4 PANGSAPURI PERMAI Phone No 0166640407


Present
address JALAN LANDAI PERMAI SUNGAI BESI Mobile /Cell No

WP KUALA LUMPUR, MALAYSIA 57100 Email address

Permanent BLOCK C 6 4 PANGSAPURI PERMAI


Address JALAN LANDAI PERMAI SUNGAI BESI
WP KUALA LUMPUR

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
PULAU PINANG
Fathers S BALAMURALI MALAYSIA MALAYSIA
INDIA
Mothers MEENAMBIKAI INDIA INDIA

Spouse

Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO


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 TOURIST VISA No of Entries MULTIPLE


Period of Visa ( Month) 6 Month Expected Date of Journey 12-JUL-2017
Port Of Arrival CHENNAI Port of Exit

SREEAKILANDESHWARI S BALAMURALI
Required Detail of TOURIST VISA
Places to be Visited CHENNAI

Purpose of Visit : INDIVIDUAL TOURIST


F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India
,

Application Id :MYSK10432317
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 of Father
Present Occupation STUDENT Designation/Rank
Employer name/business BALA CONSTRUCTION SDN BHD
Employer Address JALAN SUNGAI BESI KUALA LUMPUR
Phone Number
Past occupation if any
Are/have you worked with Armed forces/ Police/ Para Military forces ? NO
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 MALAYSIA
Nam e MR JEEVA GS TRAVEL
Address SINDUR PANTHEON PLAZA 346 PANTHEON NO 61 2ND FLOOR MEDAN BUNUS
ROAD EGMORE CHENNAI 600008 JALAN MASJID INDIA 50100 K.LUMPUR
Phone
+917299247530 0326923271
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.

..
06-JUL-2017
Date :. Applicants signature (as in Passport)