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
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
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.blsindia-usa.com after
submission, this is just the temporary ID.
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 StatusMarried
Date of birth
26-MAY-1984
ReligionCHRISTIAN
Place of Birth Town/City
WASHINGTON
Country of BirthUNITED STATES OF AMERICA
Citizenship /National ID No
123456789
Educational QualificationGRADUATE
Visible identification marks
SCAR ON FOREHEAD
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 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 NEWASHINGTON DC D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
Father’s
RICHARD SPENCER
UNITED KINGDOM
UNITED KINGDOM LONDON UNITED KINGDOMMother’s
SARAH SPENCER
UNITED KINGDOM
UNITED KINGDOM LONDONUNITED KINGDOM
Spouse
JENIFER SPENCER
UNITED STATES OF AMERICA UNITED STATES OF AMERICA WASHINGTON DCUNITED 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 EntriesSingle
Period of Visa
(Month)
3 Month
Expected Date of Journey03-SEP-2013
Port Of Arrival
DELHI
Port of ExitDELHI
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 VisitedType 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 :…