APPLICATION FORM

( Registration )

180523V3LRJJ

Application ID No. 180523V3LRJJ Final Submission Date Thu May 18 23:21:31 IST 2023

FOR OFFICE USE ONLY

Reg. No. B 0 0 1 R U S 2 0 2 3

Personal Details
Surname REPIN
Given Name ILIA Paste your
Sex Male Date of Birth 10/02/1988 Height (in cm) 178 Recent passport size
Age as on today Year(s) 35 Month(s) 3 Day(s) 8 photograph here
Place of Birth RUSSIA,KRASNODAR,RUSSIAN FEDERATION
Father's Name ALEKSANDER
Mother's Name INNA
Spouse's Name
Religion CHRISTIAN Any Identification mark(s) preferably NO
visible

Present nationality RUSSIAN FEDERATION Previous nationality RUSSIAN FEDERATION

Manner of acquiring present nationality Birth
Date of acquiring present nationality 10/02/1988
Whether holding dual NO
nationality? If yes, Name of the country of second nationality
provide the following:- Passport No. of second country
Date of Issue
Date of Expiry
Whether travelled on this passport earlier to
India

Whether person of Indian Origin NO

Address of last residence (Outside India)

Address JL. UMALAS KLECUNG NO 8X. KEROBOKAN KELOD KUTA UTARA KAB. BADUNG BALI
City BADUNG Country INDONESIA

Address intended for longer stay in India (Registration)

Address G-13 GK2 NEW DELHI - 110048
City/ District DELHI State DELHI
Pin Code 110048
Phone Number Mobile Number 9667789765
Any Other Address in India
Address 103 A SAHARA APARTMENT NEAR PANJABI VASANT KUNJ SOUTH WEST
City/ District DELHI State DELHI
Pin Code 110070
Phone Number Mobile Number 9958427958
Email/Occupation/Profession Details
E-Mail Id repinilia88@gmail.com
Profession/Occupation BUSINESS

Passport Details
Passport Number 754022133 Place of Issue RUSSIAN FEDERATION, RUSSIA
Date of Issue 07/12/2016 Expiry Date 07/12/2026

Visa Details
Visa Number 900FBCF0N Place of Issue INDIA, DELHI
Date of Issue 12/05/2023 Expiry Date 10/05/2024
Valid For Multiple Entry Visa Type e-VISA
Special endorsement, if any

Organization/Company/Institute/Hospital Details
Name
Address

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 180523V3LRJJ
Application ID No. 180523V3LRJJ

State City
Telephone Number Email ID
Employer EPFO ID Establishment ID
Arrival Details
Place of embarkation/boarding for India INDONESIA,BALI,INDONESIA
Date of arrival in India 14/05/2023
Place of disembarkation/arrival in India DELHI
Mode of Journey Air Flight/ Ship/ Bus/ Train No. 174
Purpose of visit to India Business

Previous Registration Details in India

Registration Number Place of Registration Visa Type Duration From To
Details of family members/attendant/dependents, if any accompanying.
Name Nationality Passport Number Relationship
Person to be contacted in Case of Emergency
Name SUBRAT DAS Relationship FRIEND
Address 103, A SAHARA APT, VASANTKUNJ City DELHI
Country INDIA Phone Number 9958427958
Category Others

Military service details

Organisation Designation
Rank Place of Last Posting
Country of Last Posting

Signature of the Applicant

Date_ _ _ _ _ _ _ _ _ _ _ _ _

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 180523V3LRJJ
Application ID No. 180523V3LRJJ

List of mandatory and non mandatory documents

Mandatory Documents.
1. Photo : Applicant's Photo
2. Residence proof : Residence proof i.e. updated form 'C' generated by hotel/ lodge or Registered / Notarized Lease Deed or Utility Bill copy along with copy of photo-ID of landlord with
declaration.

3. Visa : Copy of latest Indian visa

4. Passport : Bio-data page of passport

Registration office address

Office Name : FRRO NEW DELHI

Address : EAST BLOCK 8, SECTOR 1 , R.K. PURAM, NEW DELHI
City/District : DELHI
State : DELHI
Pin Code : 0
Phone Number : 01126711443

Office opening time: 9.30 closing time: 18.00

There is no need to submit hard copy to concerned

FRRO/FRO

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