Embassy of India Manila

2190 Paraiso Street,

Dasmarinas Village, Makati City

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www.embindia.org.ph
632-8430101-02

Visa Application Form

Signature

PHLM01400715

A. Personal Particulars (As in Passport)

Surname (As in Passport)
GANDEZA
Given Nam e (As in Passport) EMMA
Previous/other Name if any
Sex

Web Registration Date : 15-AUG-2015

Application Id :PHLM01400715

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

Female
04-MAY-1976
QUEZON CITY
NA
FACIAL MOLE
SINGAPORE

Marital Status
Religion
Country of Birth
Educational Qualification

Single
CHRISTIAN
PHILIPPINES
GRADUATE

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

12-SEP-2012
11-SEP-2017

Any Other Previous/Past Nationality

B. Passport Details

EB6326088
LA UNION

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

83
SAPANG MANAOAG
PANGASINAN, PHILIPPINES 2430

Phone No

+63 9490515287
Email address jatt.emma@gmail.com

Mobile /Cell No

Permanent 83
Address
SAPANG MANAOAG
PANGASINAN
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

EDUARDO GANDEZA

PHILIPPINES

PHILIPPINES

ABRA
PHILIPPINES

Mothers

LEONITA GANDEZA

PHILIPPINES

PHILIPPINES

PANGASINAN
PHILIPPINES

Spouse
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
CHENNAI

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)

EMMA GANDEZA

No of Entries
Expected Date of Journey
Port of Exit

Multiple
25-AUG-2015
CHENNAI

TOURIST VISA

Places to be Visited

CHENNAI

Purpose of Visit : OTHERS

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

NO

Application Id :PHLM01400715

Required Detail of

Cities in India Visited

Type of Visa
Visa Number
Visa Issued Place
Date of Issue
Countries visited in last 10 years
SINGAPORE
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 UN-EMPLOYED
Designation/Rank
NA
Employer name/business NA
Employer Address NA
Phone Number
Past occupation if any WORKER
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 LIPIKA ROY
Address 5/100, RAJANAGAR NEELANGARAI CHENNA
Phone
+63 94870420
Number

In
LEONITA GANDEZA

State

Phone No.

PHILIPPINES

MANAOAG PANGASINAN
09185545306

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.

15-AUG-2015
Date :.

..
Applicants signature (as in Passport)