APPLICATION FORM

( Registration )

140312B634ZF Application ID No. 140312B634ZF Appointment Date FOR OFFICE USE ONLY Reg.No. B 0 0 1 A F G 2 0 1 2 23/03/2012

Personal Details
Surname Given Name MOHAMMADULLAH Sex Male Date of Birth 04/02/1990 Age as on today Year(s) 22 Month(s) Place of Birth KANDAHAR,KANDAHAR,AFGHANISTAN Father's Name OBAIDULLAH Mother's Name Spouse Name Any Identification mark(s) preferably visible NON Present nationality AFGHANISTAN Manner of acquiring present nationality By Birth Date of acquiring present nationality Whether holding dual NO nationality? If yes, Name of the country of second nationality provide the following:- Passport No. of second country Date of Issue Date of Expiry Whether travelled on this passport earlier to India Paste your Recent passport size photograph here

Height (in cm) 1 Day(s)

0 10

Previous nationality

Whether person of Indian Origin

Address City KANDAHAR KANDAHAR

NO

Address of last residence (Outside India)

Country AFGHANISTAN

Address intended for longer stay in India (Registration)

Address INDIRA INTERNATIONAL INN City/District DELHI Pin Code Phone Number State Mobile Number DELHI

Any Other Address in India

Address INDIRA INTERNATIONAL INN City/District Pin Code Phone Number State Mobile Number DELHI

Email/Occupation/Profession Details
E-Mail Id MOHAMMADULLAH_OBAIDY@YAHOO.COM Profession/Occupation BUSINESS

Passport Details
Passport No. Date of Issue OR099382 29/07/2007 Place of Issue Expiry Date AFGHANISTAN, KANDAHAR 27/09/2013

Visa Details
Visa Number AP2994512 Date of Issue 05/02/2012 Valid For Single Entry Special endorsement, if any Place of Issue Expiry Date Visa Type VALID FOR 30 DAYS STAY AFGHANISTAN, KANDAHAR 04/05/2012 MEDICAL VISA

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140312B634ZF Application ID No. 140312B634ZF Appointment Date 23/03/2012

Organization/Company/Institute/Hospital Details
Name MD EYE CARE AND LASER CENTER Address M 165 GREATER KAILASH PART 2 State DELHI Telephone Number

City Email ID

DELHI

Arrival Details
Place of embarkation/boarding for India KABUL,KABUL,AFGHANISTAN Date of arrival in India 11/03/2012 Place of disembarkation/arrival in India DELHI Mode of Journey Air Flight /Ship /Bus /Train No. Purpose of visit to India Medical Treatement of self

Previous Registration Details in India

Registration Number Name Place of Registration Nationality Relationship Country Visa Type Duration From Passport Number FREIND INDIA To

Details of family members/attendant/dependents, if any accompanying.

Relationship

Person to be contacted in Case of Emergency

Name MOHAMMAD HAQ Address INDIRA INTERNATIONAL INN City DELHI Phone Number 9871645894

Category

Others

Military service details

Organisation Rank Country of Last Posting Designation Place of Last Posting

Signature of the Applicant Date_ _ _ _ _ _ _ _ _ _ _ _ _

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140312B634ZF Application ID No. 140312B634ZF Appointment Date 23/03/2012

Instruction
Document required for registration
1. 2. 3. 4. 5. Registration form in triplicate. 04 (for adult) and 02 (for minor) recent passport size photographs Copy of passport (photo page, Page indicating validity, page bearing arrival stamp), Copy of Indian Visa and copies of medical papers and test reports. Proof of residential address in India. Copy of valid notarized Lease/Rent agreement or copy of C-form from the Hotel and copy of recent electricity/telephone bills alongwith letter from the landlord. Letter from concerned hospital where treatment is being taken alongwith supportive medical documents/diagnostic test report with tentative period of treatment.Letter from concerned hospital where treatment is being taken alongwith supportive medical documents/diagnostic test report with RECURSIVE tentative period of treatment.

Registration office address

Office Name Address City State Pin Code Phone Number : : : : : : FRRO - NEW DELHI EAST BLOCK 8, SECTOR 1 , R.K. PURAM, NEW DELHI DELHI DELHI 011-26711443

Office opening time: 9.30 Applications are accepted upto 15.00

closing time:

18.00

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