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Visa Application Form

Signature
COLB00429016

A. Personal Particulars (As in Passport)


Surname (As in Passport) FERREIRA BALLESTEROS
Given Nam e (As in Passport) MAYERLY FERNANDA
Previous/other Name if any
Sex Female Marital Status Single
Date of birth 18-FEB-1992 Religion CHRISTIAN
ARATOCA COLOMBIA
Application Id :COLB00429016

Place of Birth Town/City Country of Birth


Citizenship /National ID No 1098357559 Educational Qualification GRADUATE
Visible identification marks NONE
Current Nationality COLOMBIA Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. AT280035 Date of issue ( dd/mm/yyyy ) 01-NOV-2016
Place of issue BOGOTA Date of expiry (dd/mm/yyyy) 01-NOV-2026
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 : 03-NOV-2016

Nationality/status
C. Applicant’s Contact Details

Present
CARRERA 16A N.1B-59 Phone No

address PIEDECUESTA Mobile /Cell No 3193871682


SANTANDER, COLOMBIA 0000 Email address fernanda.ferreira.ballesteros@gmail.com

Permanent CARRERA 16A N.1B-59


Address
PIEDECUESTA
SANTANDER

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
ARATOCA
Father’s ALIRIO FERREIRA HERNANDEZ COLOMBIA COLOMBIA COLOMBIA
SAN GIL
Mother’s CARMEN CECILIA BALLESTEROS SILVA COLOMBIA COLOMBIA COLOMBIA

Spouse

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 28-NOV-2016
Port Of Arrival NEW DELHI Port of Exit NEW DELHI

MAYERLY FERNANDA FERREIRA BALLESTEROS


Required Detail of TOURIST VISA
Places to be Visited NEW DELHI, AGRA, JAIPUR

Purpose of Visit : TOURISM


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

Application Id :COLB00429016
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 of Spouse
Present Occupation STUDENT Designation/Rank
Employer name/business FOSCAL
Employer Address CLINICA FOSCAL
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 COLOMBIA
Nam e RAJESH RAJASEKHARAN ELKIN DARIO VARGAS LOPEZ
Address 37/1622 EASTHILL KAKUZHIPALAM ROAD CALLE 64 3B 60 AP 502
KARUVASSERY(PO)CALICUT673010 KERALA
Phone
0091-9388287059 3013644260
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.

..……………………………………
03-NOV-2016
Date :………………………. Applicant’s signature (as in Passport)

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