Amount by Shri. Jamaludheen Pattambalam on remitting the fee of Rs. 50/- , vide Challan No. .. dated....

FORM 1 (see rule 5 and rule 6 (proviso)) Application for issue of permit for visit/ residence in the island for issue of fresh permit when original permit has been renewed three times. To The Administrative Officer Lakshadweep office Willington Island, Indira Gandhi Road, Kochi-3 Ph:-0484 266 6611 Sir, I Shri/ Smt/ Kumari*..son/ daughter/wife of (late*) Shrihereby apply for a permit under the Lakshadweep islands (Restrictions on Entry and Residence) Rules, 1967 authorising me and (members of my family)* to enter and remain in Minicoy/Kalpeni/Kavaratti/Agathi islands(s) of the Union Territory of the Lakshadweep islands and in that connection furnish the following particular:1. Name in full( in block letters) 2. Fathers name/Husbands name ( state whether alive and if alive, present occupation and residence)
3. Permanent address

: :

: : KASIM-K-HOMESTAY,AGATTI ISLAND ,LAKSHADWEEP

PIN: 682553

4. Address in the Island

5. Place of birth 6. Date of birth 7. Profession (with the name of the employer, if any) 8. If the applicant is not an citizen of India, state whether he is a holder of a passport or permit and if so, the following particulars of the passport or permit. (i) (ii) (iii) Number and date of issue Designation of issuing authority and place of issue Period upto which it is valid

: : :

: N/A : : N/A :

9. Previous visit to and residence in the island if any From 1. 2. 3. To

:N/A Island visited or which applicant resided No. & date of permit

10. Name and address of two persons in the Mainland to whom the applicant is well known 11. Visible to distinguishing marks of the applicant 12. Proposed period of stay in island 13. Purpose of visit to the island and details of the interest, if any in the island 14. Particulars of wife and children below 18 years of age, if any who will be accompanying the applicant( attach three copies of recent passport size photographs of self and all members of party. Pardanaship of Gosha women need not furnish photographs) 15. Whether any previous application for permit was rejected (give details)

:1. :2. : : : visit family friend

: N/A

I hereby declare that the information furnished above is correct and true to the best of my knowledge and belief.

Signature/ L.H.T impression of the applicant. Place: KOCHIN Date :

Specimen signature/ L.H.T. impression of applicant and his wife* which shall be detached and affixed to the permit.

*ORDERS OF THE COMPETENT AUTHORITY IF THE APPLICATION IS REJECTED

The above application is rejected for the following reasons:1. 2. 3. Place : Date:

*Delete not applicable

N.B. All persons above 18 years except ladies accompanying their husband shall make separate application LGP.Kvt..V.299(1)/12-09/12,000