APPLICATION FORM
( Visa Extension )
05021572AV45
Application ID No.
05021572AV45
Appointment Date
07/02/2015
FOR OFFICE USE ONLY
Reg. No.
Personal Details
Surname
YANATHAM
Given Name
PHRA MONGKOL
Sex
Male
Date of Birth
07/08/1989
Height (in cm)
Age as on today
Year(s)
25
Month(s)
5
Day(s)
Place of Birth
CHIANG RAI,CHIANG RAI,THAILAND
Father's Name
VEERA
Mother's Name
THAM
Spouse's Name
Religion
BUDDHISM
Any Identification mark(s) preferably visible
CUTTING AT FOREHEAD
Present nationality
THAILAND
Manner of acquiring present nationality
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
Whether person of Indian Origin
Paste your
Recent passport size
photograph here
163
30
Previous nationality
NO
Address of last residence (Outside India)
Address
City
120/MOO10 DONCHAI,MAESUAI
CHIANG RAI
Country
THAILAND
State
UTTAR PRADESH
Address intended for longer stay in India (Registration)
Address
ROOM NO.15 SIDDHARTH VIHAR HOSTEL,BHU
City/ District
VARANASI
Pin Code
221005
Phone Number
Mobile Number
08174894326
Any Other Address in India
Address
City/ District
Pin Code
Phone Number
State
Mobile Number
Email/Occupation/Profession Details
E-Mail Id
[email protected]
Profession/Occupation
STUDENT
Passport Details
Passport Number
Date of Issue
T700754
21/05/2012
Place of Issue
Expiry Date
THAILAND, BANGKOK
20/05/2017
Place of Issue
Expiry Date
Visa Type
THAILAND, BANGKOK
17/02/2015
STUDENT VISA
Visa Details
Visa Number
Date of Issue
Valid For
VJ2764220
18/08/2014
Multiple Entry
Page 1 of 3
05021572AV45
Application ID No.
05021572AV45
Appointment Date
07/02/2015
Special endorsement, if any
Organization/Company/Institute/Hospital Details
Name
MA IN POLITICAL SCIENCE
Address
BANARAS HINDU UNIVERSITY
State
UTTAR PRADESH
Telephone Number
Employer EPFO ID
City
Email ID
Establishment ID
VARANASI
Arrival Details
Place of embarkation/boarding for India
Date of arrival in India
Place of disembarkation/arrival in India
Mode of Journey
Air
Purpose of visit to India
Studies
BANGKOK,BANGKOK,THAILAND
22/08/2014
MUMBAI AIRPORT
Flight/ Ship/ Bus/ Train No.
Previous Registration Details in India
Registration Number
UP12RCFTHA2732014
Place of Registration
UTTAR PRADESH,VARANASI
Visa Type
STUDENT VISA
Duration From
08/12/2014
To
17/02/2015
Details of family members/attendant/dependents, if any accompanying.
Name
Nationality
Passport Number
Relationship
Person to be contacted in Case of Emergency
Name
MRS THAM YANATHAM
Address
120/MOO10 DONCHAI,MAESUAI
City
CHIANG RAI
Phone Number
0066846154377
Category
Relationship
MOTHER
Country
THAILAND
Others
Military service details
Organisation
Rank
Country of Last Posting
Designation
Place of Last Posting
Current Registration Details
Are you registered in current locality FRRO/FRO in the current visit? YES
Current
UP12RCFTHA2732014
Registration No.
Current Extension Details
Have you got extended visa in current visit in current locality
FRRO/FRO?
Current
Extension No.
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
TO STUDY
In case of Missionary - Nature of work
Signature of the Applicant
Date_ _ _ _ _ _ _ _ _ _ _ _ _
Page 2 of 3
Day(s)
05021572AV45
Application ID No.
05021572AV45
Appointment Date
07/02/2015
List of mandatory and non mandatory documents
Mandatory Documents.
1. Photo : Applicants Photo
2. Residence proof : Form C copy from Hotel or Lodge/ Electricity bill/ Landline/ Telephone /Municipal Bill of the landlord in case of staying in
a house of relative or freind along with a letter and photo-id card of the landlord.In case of rented accommodation copy of
Lease and Licence agreement (1st and last page and page containing its validity).
3. Passport and Visa : Photo page, page indicating validity, page bearing arrival stamp of Indian immigration,visa with endorsdement.
4. Financial resource proof : Bank statement copy or Proof of payment to institution.
5. RC/RP : Registration Certificate/ Residential Permit.
Non mandatory Documents.
1. Form S/ Bonafide certificate : Form S/ Bonafide certificate.
2. Others : if document type is not in the list.
Registration office address
Office Name
Address
City/District
State
Pin Code
Phone Number
:
:
:
:
:
:
FRO VARANASI
L.I.U. Office, Madagin, Kotwali Campus, Varanasi
VARANASI
UTTAR PRADESH
221002
2502655
Office opening time:
10.00
Applications are accepted upto: 15.00
closing time:
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