JL HR RASUNA SAID KAV

S-1, KUNINGAN JAKARTA SELATAN

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Visa Application Form

Signature
IDNJV0234A18

A. Personal Particulars (As in Passport)

Surname (As in Passport) NAFISAH ABD RAHMAN
Given Nam e (As in Passport) NAFISAH ABD RAHMAN
Previous/other Name if any
Sex FEMALE Marital Status SINGLE
Date of birth 14-JAN-1994 Religion ISLAM
Place of Birth Town/City SAMPANG Country of Birth INDONESIA
Application Id :IDNJV0234A18

Citizenship /National ID No 3527015401940001 Educational Qualification GRADUATE

Visible identification marks BLACK DOT AT FOREHEAD
Current Nationality INDONESIA Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. B6132655 Date of issue ( dd/mm/yyyy ) 20-JAN-2017
Place of issue TANJUNG PERAK Date of expiry (dd/mm/yyyy) 20-JAN-2022
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 : 29-NOV-2018

Nationality/status
C. Applicant’s Contact Details

DUSUN BATU PUTIH DESA SRESEH Phone No 085280198813

Present
address SAMPANG Mobile /Cell No 6285280188813
MADURA, INDONESIA 69273 Email address NAFISAHJODHARAHMAN@GMAIL.COM

Permanent DUSUN BATU PUTIH DESA SRESEH

Address SAMPANG
MADURA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
MADAPUR
Father’s MOOSA ABDUL RAHIMAN INDIA INDIA INDIA
SAMPANG
Mother’s FATIMAH BINTI MUGAMMAD SANAWI INDONESIA INDONESIA INDONESIA

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 TOURIST VISA No of Entries SINGLE

Period of Visa ( Month) 1 Month Expected Date of Journey 20-DEC-2018
Port Of Arrival BANGALORE Port of Exit BANGALORE

NAFISAH ABD RAHMAN NAFISAH ABD RAHMAN

 Required Detail of TOURIST VISA
Places to be Visited KODAGU KOLKATA BANGALORE

Purpose of Visit : INDIVIDUAL TOURIST

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

Application Id :IDNJV0234A18
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 of Father
Present Occupation STUDENT Designation/Rank STUDENT
Employer name/business IAIN KEDIRI
Employer Address JALAN SUNAN AMPEL NOMOR 7 KOTA KEDIRI
Phone Number
085280198813
Past occupation if any STUDENT
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 INDONESIA
Nam e MOOSA ABDUL RAHIMAN WASILAH
Address KODAGU KARNATAKA DUSUN BATU PUTIH DESA SRESEH
SAMPANG MADURA
Phone
+918105112055 083114053015
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.

..……………………………………
29-NOV-2018
Date :………………………. Applicant’s signature (as in Passport)