Select the center as per your jurisdiction.
This is not your Applicant ID to track your application on
www.in.ckgs.us after submission, this is just the
temporary ID.
State your Social Security
Number or state NA in case
you do not hold it.
Any visible identification mark to be
mentioned or None in case there is no visible
identification mark
If not same as your current address, it can
be the other address in the same Country or
Country of your Origin or current Nationality
This is not your Applicant ID to track your application on
www.in.ckgs.us after submission, this is just the temporary ID.
\
Reference details are mandatory. This can
be of your tentative hotel booking in
India (Strongly recommend not to make
any payments towards your hotel
reservation before Visa is granted)
Photo upload here is not mandatory.
However, it is mandatory to affix a photo
on the hard copy of form before
submitting to us even if you have uploaded
the same online.
This is not your Applicant ID to track your
application on www.in.ckgs.us after
submission, this is just the temporary ID.
Status of application can be
tracked on www.in.ckgs.us with this ID
only after us receiving the hard copy of
application form
in Post/In person and further
processing is initiated on the same.
Take print of the submitted application form and
follow instructions as advised in the illustration
below
Click here to View Photo Specification
Visa Application Form
Paste your unsigned recent
photograph. Size: 2"
X 2"
Signature/Thumb Impression of applicant
only (In case of thumb impression of
male use left hand thumb and for female
use right hand thumb)
USAC04062913
Signature
A. Personal Particulars (As in Passport)
Surname (As in Passport)
Given Name (As in Passport)
Previous/other Name if any
Sex
Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
SPENCER
DAVID BRIAN
Male
26-MAY-1984
WASHINGTON
123456789
SCAR ON FOREHEAD
Marital Status
Religion
Country of Birth
Educational Qualification
Married
CHRISTIAN
UNITED STATES OF AMERICA
GRADUATE
Current Nationality UNITED STATES OF AM Nationality by Birth/ NaturalizationNATURALIZATION
Any Other Previous/Past Nationality INDIA
B. Passport Details
Passport No. A12345678 Date of issue ( dd/mm/yyyy ) 01-JUL-2012
Place of issue WASHINGTON DC Date of expiry (dd/mm/yyyy) 01-JUL-2023
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of issue
Passport/IC No
Nationality/status
C. Applicant's Contact Details
SUITE 115
Present
Place of issue
Date of issue(dd/mm/yyyy)
Phone No
2011234567
address
Permanent
Address
220 I STREET NE
WASHINGTON DC, UNITED STATES OF AMERICA 20002
SUITE 115
220 I STREET NE
WASHINGTON DC
Mobile /Cell No
Email address
6011234567
david@aol.com
D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
LONDON
Father's
Mother's
RICHARD SPENCER
SARAH SPENCER
UNITED KINGDOM UNITED KINGDOM
UNITED KINGDOM UNITED KINGDOM
UNITED KINGDOM
LONDON
UNITED KINGDOM
WASHINGTON DC
Spouse
JENIFER SPENCER
UNITED STATES OF AMERICA
UNITED STATES OF AMERICA
UNITED STATES OF AMERICA
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) 3 Month Expected Date of Journey 03-SEP-2013
Port Of Arrival DELHI Port of Exit DELHI
DAVID BRIAN SPENCER
Web File Number
:USAC04062913
Web Registration Date : 26-AUG-2013
Required Detail of TOURIST VISA
Places to be Visited DELHI
MUMBAI
Purpose of Visit : TOURISM
F. Previous Visit Details
Have You Ever visited India ?
Addr es s w her e You s t ay ed i n
India
Cities in India Visited
Type of Visa
Visa Issued Place
Countries visited in last 10 years
UNITED KINGDOM, GERMANY
NO
,
Visa Number Date of
Issue
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 UN-EMPLOYED
Employer name/business NA
Employer Address NA
Phone Number
2011234567
Past occupation if any WORKER
Designation/Rank NA
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 UNITED STATES OF AMERICA
Name APURVA CHAUDHARY DAN SPENCER
Address COAX AND KINGS
12 LANE, ANDHERI MUMBAI
Phone 9818283888
Number
J. DECLARATION:
12 SUITE KINGSON PLACE
WA, 200304
3011234567
a.
b.
c.
d.
I do not hold any other passport(s) other than those detailed above.
I have read and understood all the conditions for the visit to India and I am willing and able to abide fully
by them .
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.
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 :26-AUG-2014
Signature/Thumb Impression of applicant
only (In case of thumb impression of
male use left hand thumb and for female
use right hand thumb)
..
Applicant's signature (as in Passport)
In case of minor, both parents signature is
mandatory in the free area below
applicant's signature line (No specific
i
ed in this case)
