High Commission of India

Menara 1 Mont Kiara, Level 28,

50480 Kuala Lumpur

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recent color photograph.
Size: 2 X 2

www.indianhighcommission.com.my
00603-6205 2350

Visa Application Form

Signature

MYSK04348716

A. Personal Particulars (As in Passport)

Surname (As in Passport)
BIN RAMLI
Given Nam e (As in Passport) ROSLAN
Previous/other Name if any

Male
16-MAY-1962
SELANGOR
620516105637
NIL
MALAYSIA

Sex

Web Registration Date : 08-MAR-2016

Application Id :MYSK04348716

Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality

Marital Status
Religion
Country of Birth
Educational Qualification

Married
ISLAM
MALAYSIA
HIGHER SECONDARY

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

13-AUG-2015
05-FEB-2021

Any Other Previous/Past Nationality

B. Passport Details

A35872352
KUALA LUMPUR

Passport No.
Place of issue

Date of expiry (dd/mm/yyyy)

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)

Nationality/status
C. Applicants Contact Details
Present
address

NO 1605-43 JALAN KG KERTAS 2

KUALA LUMPUR
WP KUALA LUMPUR, MALAYSIA 53100

Phone No
Mobile /Cell No

0133959667

Email address

Permanent NO 1605-43 JALAN KG KERTAS 2

Address
KUALA LUMPUR
WP KUALA LUMPUR
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

RAMLI

MALAYSIA

SELANGOR
MALAYSIA

Mothers

JARIAH

MALAYSIA

SELANGOR
MALAYSIA

Spouse

WAN MAHSARI

MALAYSIA

SELANGOR
MALAYSIA

Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

E. Details of Visa Sought

TOURIST VISA
(Month) 6 Month
TRICHY

Type Of Visa Required

Period of Visa
Port Of Arrival

(Visa shall be valid from the Date of Issue and not from the Date of Journey)

ROSLAN BIN RAMLI

No of Entries
Expected Date of Journey
Port of Exit

Multiple
11-MAR-2016

Required Detail of

TOURIST VISA
TRICHY

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India

YES

HOTEL VISTANA CHENNAI

NO 14/25 DEENADAYALAN STREET, T.NAGAR CHENNAI

Cities in India Visited CHENNAI

Type of Visa TOURIST VISA
Visa Issued Place KUALA LUMPUR
Countries visited in last 10 years

Application Id :MYSK04348716

Places to be Visited

VJ2937636

Visa Number
Date of Issue

01-SEP-2015

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
Present Occupation RETIRED
Designation/Rank
Employer name/business NIL
Employer Address NIL
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

I. Details of Two Reference

In India
Nam e MR JEEVA
Address SINDUR PANTHEON PLAZA 346 PANTHEON
ROAD EGMORE CHENNAI 600008

Phone
+917299247530
Number

In
GS TRAVEL

State

Phone No.

MALAYSIA

NO 61 2ND FLOOR MEDAN BUNUS

JALAN MASJID INDIA 50100 K.LUMPUR
0326923271

J. DECLARATION:
a.
b.
c.
d.

I do not hold any other passport(s) other than those detailed above.
I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them.
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.
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.

08-MAR-2016
Date :.

..
Applicants signature (as in Passport)