GOA AIRPORT

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e-Visa Application Form

Signature

I033V00B2123

A. Personal Particulars (As in Passport)

Surname KULIKOVA
Given Name ANASTASIIA
Previous Name
Gender FEMALE Marital Status SINGLE
Date of Birth 30/03/1987 Religion CHRISTIAN
Place of Birth KAPCHAGAY Country of Birth KAZAKHSTAN
File Ref No : I033V00B2123

Nationality RUSSIAN FEDERATION

Identification
marks NONE
B. Passport Details
Passport No. 757725385 Date of Issue 04/05/2018
Place of Issue MVD48001 Date of Expiry 04/05/2028
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of Issue Place of Issue
Passport/IC No. Place of Issue
C. Applicant's Contact Details
Present Address ZASHCHITNIKOV KAVKAZA 126 KRASNAYA POLYANA KRASNODARSKIY KRAY
YASTASYABERG@YANDEX.CO
Mobile Email M
D. Family Details
Relation Name Nationality Prev. Nationality Place of birth
Father's PETR KULIKOV RUSSIAN FEDERATION RUSSIAN FEDERATION KURSK
Mother's ANNA KULIKOVA RUSSIAN FEDERATION UKRAINE IVANO-FRANKOVSK
Spouse's
Were your Parents/Grandparents (paternal/maternal) Pakistan Nationals or Belong
to Pakistan held area. NO
E. Visa Details
Visa Service eTourist Visa(for 1 Year)
Period of visa 365 days No. of entries Multiple
Journey Date 11/01/2023 Port of Exit GOA AIRPORT
 F. Purpose Details
Purpose of Visit RECREATION/SIGHT-SEEING
1) Places to be visited1 GOA MORMUGAO
2) Places to be visited2
3) Have you booked any room in Hotel/Resort etc. through any
Tour Operator? NO
4) Name of the tour operator
5) Address of the tour operator
6) Name of Hotel/Resort etc
7) Place/City of Hotel/Resort etc
8) Have you ever been arrested/ prosecuted/ convicted by
Court of Law of any country? NO
9) Have you ever been refused entry / deported by any country
including India? NO
10) Have you ever been engaged in Human trafficking/ Drug
trafficking/ Child abuse/ Crime against women/ Economic
File Ref No : I033V00B2123 :: Registration Date :06/JAN/2023

offense / Financial fraud? NO

11) Have you ever been engaged in Cyber crime/ Terrorist
activities/ Sabotage/ Espionage/ Genocide/ Political killing/
other act of violence? NO
12) Have you ever by any means or medium, expressed views
that justify or glorify terrorist violence or that may encourage
others to terrorist acts or other serious criminal acts? NO
13) Have you sought asylum (political or otherwise)in any
country? NO
14) evisa_fee 40
G. Profession/Occupation Details
Present
Occupation RESTAURANT MANAGER Designation/Rank
Employer name/business OOO MAGNUM
KRASNAYA POLYANA GTZ
Employer Address GAZPROM Employer Phone
H. Details of Two Reference
In India In RUSSIAN FEDERATION
Name MARAT FARKHI ANDREY KULIKOV
WADDEM NEW WADDEM
MORMUGAO 403802 ZHELEZNOGORSK KURSKAYA ST
Address SOUTH GOA SOUTH GOA GOA MIRA 8K3 179
Phone 08322521252 +79207155647
I. 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 :06/JAN/2023