APPLICATION FORM FOR VISA FOR INDIA EMBASSY OF INDIA

PHOTO
3.5 cm x 4.5 cm
カラー証明写真
EMBASSY OF INDIA TOKYO
APPLICATION FORM FOR VISA FOR INDIA
APPLICANTS SHOULD NOTE THAT IF ANY RELEVANT INFORMATION IS WITHHELD OR IS GIVEN
INCORRECTLY, THE VISA IS LIABLE TO BE REFUSED OR, IF ALREADY ISSUED, TO BE CANCELLED
1. Type of visa required (please encircle):　ビザの種類 例 Tourism (観光) を円で囲む
Tourism / Business / Diplomatic / Official / Employment / Project / Journalist / Medical / Research / Student
(Journalists must apply for ‘J ’ visas only, irrespective of official or private visits)
/ Transit / Entry / Conference
2. Period, in months, for which visa is required: ビザの期間
6 MONTHS
3. Number of entries required: Single / Double / Multiple インド入国回数
4. Present Nationality of the applicant: 現在の国籍
JAPANESE
5. Full Name : Mr. / Mrs / Miss　名前　（パスポート姓名訂正済みの場合は訂正後の名前）
YAMADA HANAKO
6. Previous Name, if any: Mr. / Mrs / Miss　旧姓
TANAKA HANAKO または　NONE (該当がない場合）
7. Father's / Husband’s Name: Mr.
父親の名前、夫の名前 （故人の場合も記入）
FATHER: TANAKA ICHIRO　/
HUSBAND : YAMADA AKIO
8. Permanent Address:　本籍地住所
If you are non Japanese national,please write your physical address in your home country.
Address of your relatives or friends will do.
1-15-11, SHINTOMI,CHUO-KU,TOKYO,JAPAN
9. Present Address, Phone number & Email:　現住所・電話番号（携帯番号可）・Eメールアドレス
2-2-11,KUDAN MINAMI,CHIYODA-KU,TOKYO,JAPAN
03-2222-3333
EMAIL:[email protected]
(本籍地と同じ場合はSAME AS ABOVEと記入)
10. Profession / Occupation along with name of Company/ address / phone number:
職業、会社名・役職・住所・電話番号　（学生の場合は、学校名・住所・電話番号）
MANAGER OF ABC CO.,LTD. / 1-1-3,TORANOMON,MINATO-KU,TOKYO,JAPAN
03-1111-2222
11. Passport particulars:
パスポート記載事項
Passport Number:　番号　TH5000088
Date of Birth:　生年月日　16
APR 1985
01
APR 2005
Place of Birth:　出生地 Date of Expiry:失効日 01
APR 2015
Place of issue:　発行地　TOKYO,JAPAN
Date of issue:　発行日　TOKYO,JAPAN
12. Details of previous visit(s) to India, if any:　過去のインド渡航歴 （日付、場所、目的）
05SEP-10SEP 2003 MUMBAI FOR BUSINESS, 01OCT-12OCT 2011 DELHI FOR TOURISM.
または
NONE (該当がない場合）
13. Whether visa or extension of stay in India has been refused previously?
以前にインドビザ発給及び滞在延長を却下されたか
NONE (該当がない場合）
14. If so, give details 該当すればその内容を詳しく記入
NONE (該当がない場合）
15. Detailed purpose of present visit and places to be visited:　今回のインド渡航目的、場所
FOR SIGHTSEEING DELHI, AGRA, VARANASI
16.
Expected date of departure from Japan:　日本出発予定日
12 APR 2011
17.
Expected date of Entry in India:　インド入国予定日
13 APR 2011
18.
Port of entry in India:　インド入国地名
DELHI
19.
Name of destination country (for transit visas):　トランジットビザ申請の場合に次の目的国を記入
20.
NONE (該当がない場合）
Expected date and port of departure from India:　インドからの出国予定日と出国地
20 APR 2011 KOLKATA
21. Name, phone and address of two references:
ⅰ） Japan :日本国内の緊急連絡先の名前・住所・電話番号（申請者以外）
YAMADA ICHIRO
090-1234-5678 / 1-15-11, SHINTOMI,CHUO-KU,TOKYO,JAPAN
以下は観光（又は乗継）ビザ取得の記入例。　その他ビザの場合はインド受け入れ先の会社名、担当者名、住所、電話番号
ⅱ） India : インド滞在先ホテル名・住所・電話番号、または友人など
SHANGRI LA HOTEL NEW DELHI TEL:11-1191919
ADD: 19, ASHOKA ROAD, CONNAUGHT PLACE, NEW DELHI 110001
22.
Whether the applicant or his/her parents or grandparents (both paternal and maternal) were holding
the nationality of Pakistan at anytime　父または祖父（父方または母方）にパキスタン国籍を持ったことがある人はいますか
NONE (該当がない場合）
23.
Countries visited during the last 10 years:直近１０年間内に訪れた国名を記入
U.S.A., SOUTH KOREA, ITALY, CHINA, SINGAPORE, AUSTRALIA, UZBEKISTAN
24.
Whether present citizenship has been acquired by birth or naturalization　現在の国籍は生まれた時からの国籍か帰化しているか
BY BIRTH (生まれた時から）
または
NATURALIZATION （帰化している場合は、その国籍の住所を記入）
25.
Citizenship of any other country held previously　他の国籍を取得したことがありますか
NONE (該当がない場合）
または
26.
該当がある、または二重国籍の場合、その国籍名、住所を記入
The address of friends / relatives / places of stay during the previous travel to India
インドに以前行ったことがある場合は住所を記入して下さい
DELHI, ASHOK HOTEL 50-B, CHANAKYAPURI, NEW DELHI - 110 021
または
NONE (該当がない場合）
27.
From where visa(s) was / were acquired during previous visit(s) to India
インドに以前行ったことがある場合、インドビザはどこで取得したか
TOKYO JAPAN
または
NONE (該当がない場合）
28. Telephone and mobile numbers:
ⅰ） Applicant :　本人の携帯番号・または連絡可能な電話番号
ⅱ） Sponsor in India :　観光ビザ以外の場合はインド受け入れ先の会社名、担当者名、住所、電話番号
NONE (該当がない場合）
29. I confirm that all the information stated is accurate. I undertake to utilize my visit to India for the purpose for
which the visa has been applied for and for that purpose only. The visa fee paid is non refundable.
上記の内容は、真実且つ正確であり、このビザ申請内容の目的でインドを訪問することに同意します
支払い済みのビザ申請料金は返金されません
Date: 24 MAR 2011(申請日）
Place: TOKYO JAPAN
(Signature)
（署名SIGNATUREに関しての注意）　パスポートと同じ署名
パスポート所持者直筆サインのみ認めます 結婚などにより　パスポート姓名訂正後の場合もパスポート作成時の署名をして下さい。
署名が漢字の場合は同様に漢字署名をして下さい。
山田華子
PHOTO
3.5 cm x 4.5 cm
EMBASSY OF INDIA TOKYO
APPLICATION FORM FOR VISA FOR INDIA
APPLICANTS SHOULD NOTE THAT IF ANY RELEVANT INFORMATION IS WITHHELD OR IS GIVEN
INCORRECTLY, THE VISA IS LIABLE TO BE REFUSED OR, IF ALREADY ISSUED, TO BE CANCELLED
1. Type of visa required (please encircle):
Tourism / Business / Diplomatic / Official / Employment / Project / Journalist / Medical / Research / Student
/ Transit / Entry / Conference (Journalists must apply for ‘J ’ visas only, irrespective of official or private visits)
2. Period, in months, for which visa is required:
3. Number of entries required: Single / Double / Multiple
4. Present Nationality of the applicant:
5. Full Name : Mr. / Mrs / Miss
6. Previous Name, if any: Mr. / Mrs / Miss
7. Father's / Husband’s Name: Mr.
8. Permanent Address:
9. Present Address, Phone number & Email:
10. Profession / Occupation along with name of Company/ address / phone number:
11. Passport particulars:
Passport Number:
Date of Birth:
Date of issue:
Place of Birth:
Date of Expiry:
Place of issue:
12. Details of previous visit(s) to India, if any:
13. Whether visa or extension of stay in India has been refused previously?
14. If so, give details
15. Detailed purpose of present visit and places to be visited:
16. Expected date of departure from Japan:
17. Expected date of Entry in India:
18. Port of entry in India:
19. Name of destination country (for transit visas):
20. Expected date and port of departure from India:
21. Name, phone and address of two references:
ⅰ） Japan :
ⅱ） India :
22. Whether the applicant or his/her parents or grandparents (both paternal and maternal) were holding
the nationality of Pakistan at anytime
23. Countries visited during the last 10 years:
24. Whether present citizenship has been acquired by birth or naturalization
25. Citizenship of any other country held previously
26. The address of friends / relatives / places of stay during the previous travel to India
27. From where visa(s) was / were acquired during previous visit(s) to India
28. Telephone and mobile numbers:
ⅰ） Applicant
:
ⅱ） Sponsor in India :
29. I confirm that all the information stated is accurate. I undertake to utilize my visit to India for the purpose for
which the visa has been applied for and for that purpose only. The visa fee paid is non refundable.
Date:
Place:
(Signature)