DELHI AIRPORT

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e-Visa Application Form

Signature

I004W04E5219

A. Personal Particulars (As in Passport)

Surname DEELEY
Given Name THOMAS JEROME
Previous Name
Gender MALE Marital Status SINGLE
Date of Birth 22/08/1992 Religion CHRISTIAN
Place of Birth LONDON Country of Birth UNITED KINGDOM
File Ref No : I004W04E5219

Nationality UNITED KINGDOM

Identification
marks SCAR ON INNER RIGHT LEG
B. Passport Details
Passport No. 564117291 Date of Issue 04/11/2019
Place of Issue LONDON Date of Expiry 04/11/2029
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of Issue Place of Issue
Passport/IC No. Place of Issue
C. Applicant's Contact Details
Present Address FLAT 2 MARYLANDS, 29 HOLLAND ROAD FRINTON-ON-SEA ESSEX
Mobile +34634037218 Email DEELEYTJ@GMAIL.COM
D. Family Details
Relation Name Nationality Prev. Nationality Place of birth
Father's JEREMY JOHN DEELEY UNITED KINGDOM SUTTON COLDFIELD
Mother's ANNA MARIE KENNEDY UNITED KINGDOM CROYDON
Spouse's
Were your Parents/Grandparents (paternal/maternal) Pakistan Nationals or Belong
to Pakistan held area. NO
E. Visa Details
Visa Service eTourist Visa(for 1 Year)
Period of visa 365 days No. of entries Multiple
Journey Date 28/11/2019 Port of Exit DELHI AIRPORT
 F. Purpose Details
Purpose of Visit MEETING FRIENDS/RELATIVES
1) Places to be visited1 JAIPUR, GOA, MUMBAI
2) Places to be visited2
3) Have you booked any room in Hotel/Resort etc. through any
Tour Operator? NO
4) Name of the tour operator
5) Address of the tour operator
6) Name of Hotel/Resort etc
7) Place/City of Hotel/Resort etc
8) Details of the Friend/Relative AJAYRAY SHEKHAWAT SINGH
9) Address 88 PATEL NAGAR, JHOTWARA
10) State RAJASTHAN
11) District JAIPUR
File Ref No : I004W04E5219 :: Registration Date :06/NOV/2019

12) Phone no +91 96640 97465

13) Have you ever been arrested/ prosecuted/ convicted by
Court of Law of any country? NO
14) Have you ever been refused entry / deported by any
country including India? NO
15) Have you ever been engaged in Human trafficking/ Drug
trafficking/ Child abuse/ Crime against women/ Economic
offense / Financial fraud? NO
16) Have you ever been engaged in Cyber crime/ Terrorist
activities/ Sabotage/ Espionage/ Genocide/ Political killing/
other act of violence? NO
17) Have you ever by any means or medium, expressed views
that justify or glorify terrorist violence or that may encourage
others to terrorist acts or other serious criminal acts? NO
18) Have you sought asylum (political or otherwise)in any
country? NO
19) evisa_fee 40
G. Profession/Occupation Details
Present
Occupation MEDIA Designation/Rank FILMMAKER
Employer name/business SELF EMPLOYED
29 HOLLAND ROAD, FRINTON-
Employer Address ON-SEA, ESSEX, C013 9ES Employer Phone
H. Details of Two Reference
In India In UNITED KINGDOM
Name AJAYRAY SHEKHAWAT SINGH JEREMY DEELEY
88 PATEL NAGAR, FLAT 7, 56 COMMERCIAL ROAD
Address JHOTWARA LONDON E1 1LP
Phone +91 96640 97465 +447941500774
I. 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.

Date :06/NOV/2019