Name (as in passport) Leave one box blank after every part of the name/initial

Surname (Family/Last Name)

Given Name (First Name)

Spiritual Name (if any)

Date of Birth (DD/MM/YYYY) Male/Female/Other

Nationality (Country of Passport)

Permanent Address NOT in India

Address
City
State Code:
Country
Country Code
Phone +
WhatsApp Number +
Indian Mobile Phone + 91
Email Address

Emergency Contact Information

Full Name
Country Code
Phone +
Email
This person is my Mother/Father/Friend/Partner/Child/or

Health Information
I have an existing physical health problem: YES NO
If yes, please specify diagnosis
Prescription Medications

I have a history of mental illness: YES NO

If yes, please specify diagnosis
I am currently taking the following presciption medications:
Passport Details
Passport No.
Place of Issue
Date of Issue
Expiry Date

Visa or OCI Details

Number Visa Extension
Date of Issue Expiry Date
Expiration Date

Type Tourist/OCI /Student/Business/Entry or

Visa Subtype Stay Limit (no. of Days)
Place of Issue

Arrival Details
Arrived From (Country)
Arrival Port of Entry in India
Date of Arrival in India (most recent)

Date of Arrival in Amritapuri Arrival from city in India

Time of Arrival in Amritapuri
Intended Duration of Stay in Amritapuri (days)
Date of Departure from India

Other Details
Purpose of Visit Tourism/Studies/Research/Business/Other
Next Place
Destination City/District
State

Other Important Information

Languages Spoken
Profession/Job
When did you first meet Amma (month/year)

I hereby certify that the information on this card is true and correct to the
best of my knowledge

/ /
Signature day/month/year