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

Num

ber

:US

AC

0406

2913

Web

Reg

istr

atio

n D

ate

: 26-

AU

G-2

013

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)