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
MYSK12819317

A. Personal Particulars (As in Passport)

Surname (As in Passport) E CHETTIAH PILLAI
Given Nam e (As in Passport) THELAKAVATHI
Previous/other Name if any
Sex FEMALE Marital Status MARRIED
Date of birth 17-DEC-1968 Religion HINDU
SELANGOR MALAYSIA
Application Id :MYSK12819317

Place of Birth Town/City Country of Birth

Citizenship /National ID No 681217105994 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. A35325807 Date of issue ( dd/mm/yyyy ) 30-APR-2015
Place of issue UTC KUALA LUMPUR Date of expiry (dd/mm/yyyy) 17-JUL-2020
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 : 17-AUG-2017

Nationality/status
C. Applicants Contact Details

82-12-16 DE TROPICANA CONDO Phone No

Present
address JALAN KUCHAI LAMA OFF JALAN KLANG Mobile /Cell No 0107965800
KUALA LUMPUR W. PERSEKUTUAN KL, MALAYSIA 58200 Email address

Permanent 82-12-16 DE TROPICANA CONDO

Address JALAN KUCHAI LAMA OFF JALAN KLANG
KUALA LUMPUR W. PERSEKUTUAN KL

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
SELANGOR
Fathers E CHETTIAH PILLAI MALAYSIA MALAYSIA
SELANGOR
Mothers SIVAPAKIAM MALAYSIA MALAYSIA
SELANGOR
Spouse KALAI CHELVAN 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 24-AUG-2017
Port Of Arrival TIRUCHCHIRAPPALLI Port of Exit

THELAKAVATHI E CHETTIAH PILLAI

 Required Detail of TOURIST VISA
Places to be Visited TIRUCHCHIRAPPALLI

Purpose of Visit : INDIVIDUAL TOURIST

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in HOTEL GRAND GARDENIA
India
22-25 MANNARPURAM JUNCTION, TRICHY 620020 TNADU INDIA

Application Id :MYSK12819317
Cities in India Visited TRICHY
Type of Visa TOURIST VISA Visa Number VJ5486710
Visa Issued Place HIGH COMMISSION OF INDIA Date of Issue 22-JUL-2016
Countries visited in last 10 years
INDIA
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 HOUSE WIFE Designation/Rank
Employer name/business GLORY FLORIST
Employer Address 82-12-16 DE TROPICANA CONDO JALAN KUCHAI LAMA OFF
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 KALAI CHELVAN
Address 4TH FLR, SINDUR PANTHEON PLAZA 82-12-16 DE TROPICANA CONDO
346 PANTHEON ROAD EGMORE 600008 CHE JALAN KUCHAI LAMA OFF JALAN KLANG
Phone
917299247530 0107965800
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.

..
17-AUG-2017
Date :. Applicants signature (as in Passport)

Biometric Enrollment is not required till 20/07/2021.