Paste your unsigned recent color photograph. Size: 2” X 2” Visa Application Form ПОДПИСЬ Signature RUSP03089413 A. Personal Particulars (As in Passport) Surname (As in Passport) IVANOVA Given Nam e (As in Passport) IRINA Previous/other Name if any Female 03-MAY-1974 LENINGRAD NA NO RUSSIAN FEDERATION Web Registration Date : 18-DEC-2013 Web File Number :RUSP03089413 Sex Date of birth Place of Birth Town/City Citizenship /National ID No Visible identification marks Current Nationality Marital Status Religion Country of Birth Educational Qualification Married CHRISTIAN RUSSIAN FEDERATION GRADUATE Nationality by Birth/ Naturalization BY BIRTH Date of issue ( dd/mm/yyyy ) 10-DEC-2010 10-DEC-2020 Any Other Previous/Past Nationality B. Passport Details 729269575 ST PETERSBURG Passport No. Place of issue Date of expiry (dd/mm/yyyy) 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) Nationality/status C. Applicant’s Contact Details Present address MARATA STR 47 ST PETERSBURG Phone No 78123330630 78123330630 Email address [email protected] Mobile /Cell No ST PETERSBURG, RUSSIAN FEDERATION 191002 Permanent MARATA STR 47 Address ST PETERSBURG ST PETERSBURG D. Family Details Relation Name Nationality Prev. Nationality Place/Country of Birth LENINGRAD RUSSIAN FEDERATION RUSSIAN FEDERATION Father’s ANDREY RUSSIAN FEDERATION Mother’s ELENA RUSSIAN FEDERATION RUSSIAN FEDERATION RUSSIAN FEDERATION Spouse IVANOV IGOR RUSSIAN FEDERATION RUSSIAN FEDERATION RUSSIAN FEDERATION LENINGRAD LENINGRAD Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO E. Details of Visa Sought TOURIST VISA (Month) 26 Month Month GOA Type Of Visa Required Period of Visa Port Of Arrival (Visa shall be valid from the Date of Issue and not from the Date of Journey) IRINA IVANOVA No of Entries Expected Date of Journey Port of Exit Single 25-DEC-2013 GOA Required Detail of TOURIST VISA GOA Purpose of Visit : TOURISM F. Previous Visit Details Have You Ever visited India ? Address where You stayed in India NO Web File Number :RUSP03089413 Places to be Visited , Cities in India Visited Type of Visa Visa Number Visa Issued Place Date of Issue Countries visited in last 10 years EGYPT FINLAND 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 ENGINEER Designation/Rank Employer name/business KRASAVA COMPANY Employer Address ST PETERSBURG LIGOVSKY AVE 11 Phone Number 78123330630 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 I. Details of Two Reference In India Nam e CONCORD EXOTIC VOYAGES INDIA PVT LTD Address G 293 1ST FLOOR PANAMPILLY AVE KOCHI INDIA Phone 914842318002 Number In BIBLIO GLOBUS State Phone No. RUSSIAN FEDERATION ST PETERSBURG MARATA 47 49 RUSSIA 78123330630 J. DECLARATION: 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. ПОДПИСЬ 18-DEC-2013 Date :………………………. ..…………………………………… Applicant’s signature (as in Passport)