Consulate General of India

Level 6, 12 St. Georges Terrace,

Perth, WA 6000 Paste your unsigned
recent color photograph.
0061-8-92214205 Size: 2” X 2”

Visa Application Form

Signature
AUSP00599018

A. Personal Particulars (As in Passport)

Surname (As in Passport) SELLATHAMBI
Given Nam e (As in Passport) VASANTHAKUMAR
Previous/other Name if any
Sex MALE Marital Status SINGLE
Date of birth 07-JAN-1984 Religion HINDU
MULLAITIVU SRI LANKA
Application Id :AUSP00599018

Place of Birth Town/City Country of Birth

Citizenship /National ID No PU0077017 Educational Qualification MATRICULATION
Visible identification marks A CUT BELOW RIGHT EYE
Current Nationality SRI LANKA Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. PU0077017 Date of issue ( dd/mm/yyyy ) 22-MAY-2018
Place of issue AUSTRALIA Date of expiry (dd/mm/yyyy) 22-MAY-2020
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 : 29-DEC-2018

Nationality/status
C. Applicant’s Contact Details

5 BAXENDALE WAY Phone No

Present
address CAMILLO 61491286906
Mobile /Cell No

WESTERN AUSTRALIA, AUSTRALIA 6111 Email address VVASU0184@GMAIL.COM

Permanent 5 BAXENDALE WAY

Address CAMILLO
WESTERN AUSTRALIA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
MULLAITIVU
Father’s SELLATHAMBI SRI LANKA SRI LANKA SRI LANKA
MULLAITIVU
Mother’s PACHAIYAMMA SRI LANKA SRI LANKA SRI LANKA

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 SINGLE

Period of Visa ( Month) 1 Month Expected Date of Journey 01-MAR-2019
Port Of Arrival CHENNAI Port of Exit CHENNAI

VASANTHAKUMAR SELLATHAMBI
 Required Detail of TOURIST VISA
Places to be Visited CHENNAI
TAMILNADU

Purpose of Visit : INDIVIDUAL TOURIST

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

Application Id :AUSP00599018
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 WORKER Designation/Rank FORKLIFT OPERATOR
Employer name/business CLEAN DRUM CO PTY LTD
Employer Address 5 PUSEY ROAD COCKBURN CENTRAL WA 6164
Phone Number
0894147244
Past occupation if any WORKER
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 SRI LANKA
Nam e DHANAPALASINGAM PACHAIYAMMA
Address 12/83 KANNADASAN SALAI, MOGAPPAIR E UDUPPUKKULAM ALMPIL
CHENNAI 37 MULLAITIVU
Phone
07397634372 0770207826
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.

..……………………………………
29-DEC-2018
Date :………………………. Applicant’s signature (as in Passport)