HCI COLOMBO

36-38 GALLE ROAD, P O BOX NO 882

COLOMBO 3, SRI LANKA Paste your unsigned
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Visa Application Form

Signature
LKAC07171016

A. Personal Particulars (As in Passport)

Surname (As in Passport) ATHAMLEBBE
Given Nam e (As in Passport) ATHAMLEBBE MOHAMED BAZEER
Previous/other Name if any
Sex Male Marital Status Married
Date of birth 17-MAR-1972 Religion ISLAM
Place of Birth Town/City KATTANKUDDY Country of Birth SRI LANKA
Application Id :LKAC07171016

Citizenship /National ID No 720772140V Educational Qualification HIGHER SECONDARY

Visible identification marks FARE
Current Nationality SRI LANKA Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. N3631058 Date of issue ( dd/mm/yyyy ) 25-NOV-2013
Place of issue SRI LANKA Date of expiry (dd/mm/yyyy) 25-NOV-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)
Web Registration Date : 29-APR-2016

Nationality/status
C. Applicant’s Contact Details

Present
NO,6 MAIN STREET KATTANKKUDY Phone No

address KATTANKKUDY Mobile /Cell No 0777360470

EASTERN PROVINCE, SRI LANKA 30100 Email address

Permanent NO,6 MAIN STREET KATTANKKUDY

Address
KATTANKKUDY
EASTERN PROVINCE

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KATTANKKUDY
Father’s M T ATHAMLEBBE SRI LANKA SRI LANKA SRI LANKA
KATTANKKUDY
Mother’s SUBAITHA UMMA SRI LANKA SRI LANKA SRI LANKA
KATTANKKUDY
Spouse A R JAHANIYA SRI LANKA SRI LANKA SRI LANKA
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 07-MAY-2016
Port Of Arrival ALL PORT Port of Exit ALL PORT

ATHAMLEBBE MOHAMED BAZEER ATHAMLEBBE

 Required Detail of TOURIST VISA
Places to be Visited CHENNAI BANGALORE

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India
,

Application Id :LKAC07171016
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years
SAUDI ARABIA
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 BUSINESS PERSON Designation/Rank OWNER
Employer name/business NEW CITY HARDWARE
Employer Address 06 MAIN STREET KATTANKKUDY
Phone Number
0777360470
Past occupation if any BUSINESS PERSON
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 SRI LANKA
Nam e WHITE PALACE INDIA A R JAHANIYA
Address NO. 183, OLD 160, ANGAPPA NAICKEN NO 06, MAIN STREET KATTANKKUDY
STREET MANNADI, NEAR CHENNAI
Phone
+91 44 2521 090 0771972709
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.

..……………………………………
29-APR-2016
Date :………………………. Applicant’s signature (as in Passport)