High Commission of India

Menara 1 Mont Kiara, Level 28,

50480 Kuala Lumpur Paste your unsigned
www.indianhighcommission.com.my recent color photograph.
00603-6205 2350 Size: 2 X 2

Visa Application Form

Signature
MYSK10442317

A. Personal Particulars (As in Passport)

Surname (As in Passport)
Given Nam e (As in Passport) SATHIASEELAN CHANDRASEKARAN
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 29-DEC-1972 Religion HINDU
SELANGOR MALAYSIA
Application Id :MYSK10442317

Place of Birth Town/City Country of Birth

Citizenship /National ID No 721229105995 Educational Qualification HIGHER SECONDARY
Visible identification marks NIL
Current Nationality MALAYSIA Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. A40454242 Date of issue ( dd/mm/yyyy ) 20-JUN-2017
Place of issue PEL KELANG Date of expiry (dd/mm/yyyy) 13-DEC-2022
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 : 06-JUL-2017

Nationality/status
C. Applicants Contact Details

NO 16 JALAN DESA 3/2 BANDAR COUNTRY Phone No 0192609038

Present
address RAWANG Mobile /Cell No

SELANGOR, MALAYSIA 48000 Email address

Permanent NO 16 JALAN DESA 3/2 BANDAR COUNTRY

Address RAWANG
SELANGOR

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
SELANGOR
Fathers CHANDRASEKARAN MALAYSIA MALAYSIA
SELANGOR
Mothers SATHIA MALAYSIA MALAYSIA
SELANGOR
Spouse AMUTHAVALLI MALAYSIA MALAYSIA
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 MULTIPLE

Period of Visa ( Month) 6 Month Expected Date of Journey 27-JUL-2017
Port Of Arrival CHENNAI Port of Exit

SATHIASEELAN CHANDRASEKARAN
 Required Detail of TOURIST VISA
Places to be Visited CHENNAI

Purpose of Visit : INDIVIDUAL TOURIST

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

Application Id :MYSK10442317
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years

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 SELF EMPLOYED/ FREELANCER Designation/Rank
Employer name/business NIL
Employer Address NIL
Phone Number
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 State Phone No.

I. Details of Two Reference

In India In MALAYSIA
Nam e JEEVA AMUTHAVALLI
Address 4TH FLR SIDNUR PANTHEON PLAZAA NO 16 JALAN DESA 3/2
PANTHEON ROAD EGMORE 6000008 CHENNA RAWANG 480000
Phone
91729924730 0192609038
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.

..
06-JUL-2017
Date :. Applicants signature (as in Passport)