APPLICATION FORM

( Registration )
170714ZMBI28
Application ID No. 170714ZMBI28 Appointment Date 21/07/2014
FOR OFFICE USE ONLY
Reg. No. B 0 0 3 N G A 2 0 1 4
Personal Details
Surname NWACHUKWU
Given Name MARYANN ADAEZE
Sex Female Date of Birth 05/05/1993 Height (in cm) 158
Age as on today Year(s) 21 Month(s) 2 Day(s) 12
Place of Birth LAGOS,LAGOS,NIGERIA
Father's Name JOSEPH NWACHUKWU
Mother's Name EMELDA NWACHUKWU
Spouse's Name
Any Identification mark(s) preferably visible NO
Paste your
Recent passport size
photograph here
Present nationality NIGERIA Previous nationality NIGERIA
Manner of acquiring present nationality Birth
Date of acquiring present nationality
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 18 ALOWONLE STR. IDI-OROGBO OLA-OGUN AGBADO
City LAGOS Country NIGERIA
Address intended for longer stay in India (Registration)
Address NO 76, 3RD FLOOR, SALEEM BUILDING, POTHALAPPA GARDEN, ADUGODI,
City/ District BANGALURU State KARNATAKA
Pin Code 560030
Phone Number Mobile Number 9538334203
Any Other Address in India
Address
City/ District State
Pin Code
Phone Number Mobile Number
Email/Occupation/Profession Details
E-Mail Id nwachukwu.maryannadaeze@yahoo.com
Profession/Occupation STUDENT
Passport Details
Passport Number A04615810 Place of Issue NIGERIA, LAGOS
Date of Issue 25/03/2013 Expiry Date 24/03/2018
Visa Details
Visa Number 1173716 Place of Issue NIGERIA, LAGOS
Date of Issue 11/07/2014 Expiry Date 10/01/2015
Valid For Single Entry Visa Type STUDENT VISA
Special endorsement, if any
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170714ZMBI28
Application ID No. 170714ZMBI28 Appointment Date 21/07/2014
Organization/Company/Institute/Hospital Details
Name ST HOPKINS COLLEGE OF MANAGEMENT
Address 53/1 SUBBANNA GARDEN, ADUGODI, BANNERGHATTA ROAD CROSS,
State KARNATAKA City BANGALURU
Telephone Number 08022113435 Email ID hopkinscollege2012@gmail.com
Arrival Details
Place of embarkation/boarding for India LAGOS,LAGOS,NIGERIA
Date of arrival in India 14/07/2014
Place of disembarkation/arrival in India MUMBAI AIRPORT
Mode of Journey Air Flight/ Ship/ Bus/ Train No. ET610
Purpose of visit to India Studies
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 SYED MD IRFAN Relationship
Address NO 76, 3RD FLOOR, SALEEM BUILDING, POTHALAPPA GARDEN, ADUGODI,
City BANGALORE Country INDIA
Phone Number 08022113435
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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170714ZMBI28
Application ID No. 170714ZMBI28 Appointment Date 21/07/2014
List of mandatory and non mandatory documents
Mandatory Documents.
1. Photo : Applicants Photo
2. Residence proof : Form C copy from Hotel or Lodge/ Electricity bill/ Landline/ Telephone /Municipal Bill of the landlord in case of staying in a house of relative or freind along with
a letter and photo-id card of the landlord.In case of rented accommodation copy of Lease and Licence agreement (1st and last page and page containing its validity).
3. Form S/ Bonafide certificate : Form S/ Bonafide certificate.
4. Passport and Visa : Photo page, page indicating validity, page bearing arrival stamp of Indian immigration,visa with endorsdement.
Non mandatory Documents.
1. Others : if document type is not in the list.
Registration office address
Office Name : FRRO BENGALURU
Address : 5th Floor, A Block, TTMC, BMTC Bus Stand Building, K.H. Road, Shantinagar
City/District : BANGALURU
State : KARNATAKA
Pin Code : 560027
Phone Number : 0
Office opening time: 9.30 closing time: 18.00
Applications are accepted upto: 14.00
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