APPLICATION FOR ISSUE OF AN INDIAN EMERGENCY CERTIFICATE

Please fill the form in CAPITAL LETTERS.

Please use DD/MM/YYYY format for date.
Please affix one recent photograph.
Fee: Dhs.20/- (Twenty only)
Full Name: _____________________________________________________________________________________
Aliases if any: __________________________________________________________________________________
Maiden name (In case of married/widow/divorcee): __________________________________________________
Father's/husband's name: ________________________________________________________________________
Mother's name: _________________________________________________________________________________
Date of birth: ___________________

Place of birth: ___________________________________________

Village/Town: __________________________ Dist: ____________________________State: _________________

Permanent Address in India:

Address in U.A.E

______________________________________________

____________________________________

______________________________________________

____________________________________

______________________________________________

Tel: _______________________________

State: ____________________________________
Nationality: _____________________________

Profession: ________________________

Particulars of Passport /travel document:

PassportNo: __________________ Date of Issue: __________________

Place of issue: _____________________________

If passport particulars are not available please give reasons: _________________________________________________________

____________________________________________________________________________________________________________________

Visible distinguishing mark: _______________________________________________________________________________________

-2Arrival Details:
Arrival date: ____________________________________

By flight/Ship No. _________________________________________________

Place of arrival in UAE: _________________________

From: ______________________________________________________

Name and details of local sponsor: ____________________________________________________________

Name and details of Indian agent, if any: ____________________________________________________________
Names/Addresses of relatives or friends in UAE who can stand guarantee:
No.

Name

Relationship

Address

Passport No. with

place/date of issue

Telephone No.

References in India: (Names & addresses of two persons who can be contacted for information):
No.
1.

Name

Address

Telephone No.

2.

Approximate date of travel to India: ______________________________________________________________________

Port of disembarkation in India: _________________________________________________________________________
(Thumb impression)

Photograph of Bearer

(Left for Male & Right for Female)

Affix Photo

(Signature of Applicant)

-3Details of Imprisonment (In case of prison inmates}:

a) When and where arrested: ______________________________________________________________________________
b) Details of prosecution: ________________________________________________________________________________
c) Name of Court: ______________________________________________________________________________________
d) Judgement of court: ___________________________________________________________________________________

Declaration of applicant:
I solemnly declare that I am a citizen of India/person of Indian origin. I have not voluntarily acquired citizenship of another
country and I owe allegiance to India. I have not lost, surrendered or been deprived of citizenship of India. The information
given by me in this form is true.
(Signature / Thumb Impression)
PLACE: ____________________________________
DATE: ____________________________________

Details of Nationality Proof Documents:1. ____________________________________

2. ____________________________________

3. ____________________________________

4. ____________________________________

Interview details:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

The applicant is Indian

Name & Signature of

Consular Assistant

Name & Signature of

Consul/Vice Consul

Name & Signature of

Representative

-4For Office use only