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Embassy of India

H.No. 5 Street-466 Phnom Penh, Cambodia


Paste your unsigned
httpp://www.indembassyphnompenh.org recent color photograph.
855-23-210912 Size: 2” X 2”

Visa Application Form

Signature
KHMPV00C4818

A. Personal Particulars (As in Passport)


Surname (As in Passport) KUCH
Given Nam e (As in Passport) SAVARETH
Previous/other Name if any
Sex MALE Marital Status SINGLE
Date of birth 14-NOV-1992 Religion BUDDHISM
Application Id :KHMPV00C4818

Place of Birth Town/City KANDAL Country of Birth CAMBODIA


Citizenship /National ID No 020894186 Educational Qualification GRADUATE
Visible identification marks A MOLE ABOVE THE LEFT NOSEBLADE
Current Nationality CAMBODIA Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. N01027492 Date of issue ( dd/mm/yyyy ) 28-SEP-2017
Place of issue MIN PHNOM PENH Date of expiry (dd/mm/yyyy) 28-SEP-2027
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 : 04-JUL-2018

Nationality/status
C. Applicant’s Contact Details

41 Phone No 85578829209
Present
address PHIRI Mobile /Cell No

KANDAL, CAMBODIA 08367 Email address KUCHSAVARETH@GMAIL.COM

Permanent 41
Address PHIRI
KANDAL

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KANDAL
Father’s KUCH CHANTHOL CAMBODIA CAMBODIA
KANDAL
Mother’s SAN SOKHENG CAMBODIA CAMBODIA

Spouse

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 STUDENT VISA No of Entries SINGLE


Period of Visa ( Month) 2 Month Expected Date of Journey 15-JUL-2018
Port Of Arrival RGI AIRPORT Port of Exit RGI AIRPORT

SAVARETH KUCH
Required Detail of STUDENT VISA
Institution REC INSTITUTE OF POWER MANAGEMENT AND TRAINING 1MONTH
Address ARAMGHAR NATIONAL HIGHWAY NO. 7,HYDERAB
Phone +91 40 2980 590
Email RECIPMTTRG@RECL.NIC.IN
Course Detail CONCEPT TO COMMISSIONING OF SOLAR POWER PLANTS

Purpose of Visit : SHORT TERM COURSES


F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India
,

Application Id :KHMPV00C4818
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years

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 ENGINEER Designation/Rank EDC
Employer name/business EDC
Employer Address PHNOM PENH
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 CAMBODIA
Nam e SHRI G.SHANKER KHUN CHANTHEA
Address ARAMGHAR NATIONAL HIGHWAY NO. 7,HYD PHNOM PENH

Phone
+91 40 2980 590 85578666178
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.

..……………………………………
04-JUL-2018
Date :………………………. Applicant’s signature (as in Passport)

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