APPLICATION FORM

( Visa Extension )

230313C5ACL0
Application ID No.

230313C5ACL0

Appointment Date

01/04/2013

FOR OFFICE USE ONLY

Reg. No.

Personal Details
Surname

KRISHNADASAN

Given Name
Sex
Male

CUMARASWAMY
Date of Birth

Age as on today

Year(s)

Paste your

73

08/01/1940

Height (in cm)

181

Month(s)

15

Place of Birth
Father's Name

SRILANKA,JAFFNA,SRI LANKA
CUMARASWAMY

Mother's Name
Spouse's Name

SIVAPAKIAM
NEMANI VENKATA KAMESWARI SREEDEVI

Any Identification mark(s) preferably visible

OPERATIVE SCAR RIGHT SIDE OF CHEST

Present nationality
UNITED STATES OF AMERICA
Manner of acquiring present nationality
Naturalization
Date of acquiring present nationality
29/08/1986
Whether holding dual
nationality? If yes,
provide the following:-

Day(s)

Recent passport size

photograph here

Previous nationality

SRI LANKA

NO
Name of the country of second nationality
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
City

6036 DEVONSHIRE DRIVE

PALMDALE CALIFORNIA

Country

UNITED STATES OF AMERICA

Address intended for longer stay in India (Registration)

Address
SITE NO.45 HL KHATHA NO.70 SITUATED IN MARASANDRA
City/District
BANGALURU
State
Pin Code
Phone Number
Mobile Number

KARNATAKA
9052232846

Any Other Address in India

Address
City/District
Pin Code
Phone Number

State
Mobile Number

Email/Occupation/Profession Details
E-Mail Id
ckrishnadasan@gmail.com
Profession/Occupation
RETIRED

Passport Details
Passport Number
Date of Issue

217220327
24/02/2006

Place of Issue
Expiry Date

UNITED STATES OF AMERICA, USA

23/02/2016

Place of Issue
Expiry Date
Visa Type

UNITED STATES OF AMERICA, SANFRANCISCO

12/05/2013
LONG TERM VISA

Visa Details
Visa Number
AJ785946
Date of Issue
13/05/2010
Valid For
Multiple Entry
Special endorsement, if any

STAY VISA

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230313C5ACL0
Application ID No.

230313C5ACL0

Appointment Date

01/04/2013

Organization/Company/Institute/Hospital Details
Name
Address
State

City

Telephone Number

Email ID

Arrival Details
Place of embarkation/boarding for India

USA,LOSANGELES,UNITED STATES OF AMERICA

Date of arrival in India

Place of disembarkation/arrival in India

12/03/2013
BANGALORE

Mode of Journey
Air
Purpose of visit to India

Flight /Ship /Bus /Train No.

LH754

Joining spouse

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
Address
City

NEMANI SREEEDEVI
Relationship
SITE NO 45 HL KATHA NO70 MARASANDRA VILLGE
BANGALORE
Country

Phone Number

Category

WIFE
INDIA

9441951032
Others

Military service details

Organisation
Rank

Designation
Place of Last Posting

Country of Last Posting

Current Registration Details

Are you registered in current locality FRRO/FRO in the current visit? NO

Current
Registration No.

Current Extension Details

Have you got extended visa in current visit in current locality
FRRO/FRO?

YES

Current
Extension No.

B003RCFUSA0165682010

Visa Extension Details

Wether Previously in India?
Whether Permission to stay in India has been Previously refused?
Whether Permission to extend stay in India has been Previously
granted?
Period of Extension requried
Year(s)
1
Month(s)
Reason for extension
MARRIED INDIAN
In case of Missionary - Nature of work

Signature of the Applicant

Date_ _ _ _ _ _ _ _ _ _ _ _ _

Page 2 of 3

Day(s)

230313C5ACL0
Application ID No.

230313C5ACL0

Appointment Date

Instruction
Click here to Download Instruction For Visa Extension

Registration office address

Office Name

FRRO BENGALURU

Address
City

:
:

BENGALURU
BANGALURU

State
Pin Code
Phone Number

:
:
:

KARNATAKA
0
0

Office opening time:

9.30

closing time:

Applications are accepted upto 16.00

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01/04/2013