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(1)

This is not your Applicant ID to track your application on

www.blsindia-usa.com 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

(2)
(3)

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

(4)
(5)

\

This is not your Applicant ID to track your application on

(6)

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.

(7)

This is not your Applicant ID to track your

application on www.blsindia-usa.com after

submission, this is just the temporary ID.

(8)
(9)
(10)
(11)
(12)

Status of application can be tracked

on www.blsindia-usa.com 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

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Paste your unsigned recent

color photograph. Size: 2”

X 2”

Visa Application Form

USAC04062913

Signature

A. Personal Particulars (As in Passport)

Surname (As in Passport)

SPENCER

Given Name (As in Passport)

DAVID BRIAN

Previous/other Name if any

Sex

Male

Marital Status

Married

Date of birth

26-MAY-1984

Religion

CHRISTIAN

Place of Birth Town/City

WASHINGTON

Country of Birth

UNITED STATES OF AMERICA

Citizenship /National ID No

123456789

Educational Qualification

GRADUATE

Visible identification marks

SCAR ON FOREHEAD

Current Nationality

UNITED STATES OF AM

Nationality by Birth/ Naturalization

NATURALIZATION

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 Place of issue

Passport/IC No Date of issue(dd/mm/yyyy)

Nationality/status

C. Applicant’s Contact Details Present

address

SUITE 115

220 I STREET NE

WASHINGTON DC, UNITED STATES OF AMERICA 20002

Phone No

2011234567

Mobile /Cell No

6011234567

Email address

david@aol.com

Permanent

Address

SUITE 115

220 I STREET NE

WASHINGTON DC D. Family Details

Relation Name Nationality Prev. Nationality Place/Country of Birth

Father’s

RICHARD SPENCER

UNITED KINGDOM

UNITED KINGDOM LONDON UNITED KINGDOM

Mother’s

SARAH SPENCER

UNITED KINGDOM

UNITED KINGDOM LONDON

UNITED KINGDOM

Spouse

JENIFER SPENCER

UNITED STATES OF AMERICA UNITED STATES OF AMERICA WASHINGTON DC

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

D A V ID BR IAN S PEN C ER

Signature/Thumb Impression of applicant

only (In case of thumb impression of male

use left hand thumb and for female use

right hand thumb)

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Required Detail of

TOURIST VISA

Places to be Visited DELHI

MUMBAI

Purpose of Visit :

TOURISM

F. Previous Visit Details

Have You Ever visited India ? NO

Address where You stayed in India

,

Cities in India Visited

Type of Visa Visa Number

Visa Issued Place Date of Issue

Countries visited in last 10 years UNITED KINGDOM, GERMANY

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 Designation/Rank NA

Employer name/business NA

Employer Address

Phone Number NA 2011234567

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

UNITED STATES OF AMERICA

Name APURVA CHAUDHARY DAN SPENCER

Address COAX AND KINGS

12 LANE, ANDHERI MUMBAI

9818283888

12 SUITE KINGSON PLACE

WA, 200304 3011234567

Phone 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.

..………

Date :…

26

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-2

01

3

………. Applicant’s signature (as in Passport)

Signature/Thumb Impression of applicant

only (In case of thumb impression of

male use left hand thumb and for female

use right hand thumb)

In case of minor, both parents signature is

mandatory in the free area below

applicant’s signature line (No specific field

is to be used in this case)

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