PHOTO 3.5 cm x 4.5 cm カラー証明写真 EMBASSY OF INDIA TOKYO APPLICATION FORM FOR VISA FOR INDIA APPLICANTS SHOULD NOTE THAT IF ANY RELEVANT INFORMATION IS WITHHELD OR IS GIVEN INCORRECTLY, THE VISA IS LIABLE TO BE REFUSED OR, IF ALREADY ISSUED, TO BE CANCELLED 1. Type of visa required (please encircle):　ビザの種類例 Tourism (観光) を円で囲む Tourism / Business / Diplomatic / Official / Employment / Project / Journalist / Medical / Research / Student (Journalists must apply for ‘J ’ visas only, irrespective of official or private visits) / Transit / Entry / Conference 2. Period, in months, for which visa is required: ビザの期間 6 MONTHS 3. Number of entries required: Single / Double / Multiple インド入国回数 4. Present Nationality of the applicant: 現在の国籍 JAPANESE 5. Full Name : Mr. / Mrs / Miss　名前　（パスポート姓名訂正済みの場合は訂正後の名前） YAMADA HANAKO 6. Previous Name, if any: Mr. / Mrs / Miss　旧姓 TANAKA HANAKO または　NONE (該当がない場合） 7. Father's / Husband’s Name: Mr. 父親の名前、夫の名前（故人の場合も記入） FATHER: TANAKA ICHIRO　/ HUSBAND : YAMADA AKIO 8. Permanent Address:　本籍地住所 If you are non Japanese national,please write your physical address in your home country. Address of your relatives or friends will do. 1-15-11, SHINTOMI,CHUO-KU,TOKYO,JAPAN 9. Present Address, Phone number & Email:　現住所・電話番号（携帯番号可）・Eメールアドレス 2-2-11,KUDAN MINAMI,CHIYODA-KU,TOKYO,JAPAN 03-2222-3333 EMAIL:[email protected] (本籍地と同じ場合はSAME AS ABOVEと記入) 10. Profession / Occupation along with name of Company/ address / phone number: 職業、会社名・役職・住所・電話番号　（学生の場合は、学校名・住所・電話番号） MANAGER OF ABC CO.,LTD. / 1-1-3,TORANOMON,MINATO-KU,TOKYO,JAPAN 03-1111-2222 11. Passport particulars: パスポート記載事項 Passport Number:　番号　TH5000088 Date of Birth:　生年月日　16 APR 1985 01 APR 2005 Place of Birth:　出生地 Date of Expiry:失効日 01 APR 2015 Place of issue:　発行地　TOKYO,JAPAN Date of issue:　発行日　TOKYO,JAPAN 12. Details of previous visit(s) to India, if any:　過去のインド渡航歴（日付、場所、目的） 05SEP-10SEP 2003 MUMBAI FOR BUSINESS, 01OCT-12OCT 2011 DELHI FOR TOURISM. または NONE (該当がない場合） 13. Whether visa or extension of stay in India has been refused previously? 以前にインドビザ発給及び滞在延長を却下されたか NONE (該当がない場合） 14. If so, give details 該当すればその内容を詳しく記入 NONE (該当がない場合） 15. Detailed purpose of present visit and places to be visited:　今回のインド渡航目的、場所 FOR SIGHTSEEING DELHI, AGRA, VARANASI 16. Expected date of departure from Japan:　日本出発予定日 12 APR 2011 17. Expected date of Entry in India:　インド入国予定日 13 APR 2011 18. Port of entry in India:　インド入国地名 DELHI 19. Name of destination country (for transit visas):　トランジットビザ申請の場合に次の目的国を記入 20. NONE (該当がない場合） Expected date and port of departure from India:　インドからの出国予定日と出国地 20 APR 2011 KOLKATA 21. Name, phone and address of two references: ⅰ） Japan :日本国内の緊急連絡先の名前・住所・電話番号（申請者以外） YAMADA ICHIRO 090-1234-5678 / 1-15-11, SHINTOMI,CHUO-KU,TOKYO,JAPAN 以下は観光（又は乗継）ビザ取得の記入例。　その他ビザの場合はインド受け入れ先の会社名、担当者名、住所、電話番号 ⅱ） India : インド滞在先ホテル名・住所・電話番号、または友人など SHANGRI LA HOTEL NEW DELHI TEL:11-1191919 ADD: 19, ASHOKA ROAD, CONNAUGHT PLACE, NEW DELHI 110001 22. Whether the applicant or his/her parents or grandparents (both paternal and maternal) were holding the nationality of Pakistan at anytime　父または祖父（父方または母方）にパキスタン国籍を持ったことがある人はいますか NONE (該当がない場合） 23. Countries visited during the last 10 years:直近１０年間内に訪れた国名を記入 U.S.A., SOUTH KOREA, ITALY, CHINA, SINGAPORE, AUSTRALIA, UZBEKISTAN 24. Whether present citizenship has been acquired by birth or naturalization　現在の国籍は生まれた時からの国籍か帰化しているか BY BIRTH (生まれた時から）または NATURALIZATION （帰化している場合は、その国籍の住所を記入） 25. Citizenship of any other country held previously　他の国籍を取得したことがありますか NONE (該当がない場合）または 26. 該当がある、または二重国籍の場合、その国籍名、住所を記入 The address of friends / relatives / places of stay during the previous travel to India インドに以前行ったことがある場合は住所を記入して下さい DELHI, ASHOK HOTEL 50-B, CHANAKYAPURI, NEW DELHI - 110 021 または NONE (該当がない場合） 27. From where visa(s) was / were acquired during previous visit(s) to India インドに以前行ったことがある場合、インドビザはどこで取得したか TOKYO JAPAN または NONE (該当がない場合） 28. Telephone and mobile numbers: ⅰ） Applicant :　本人の携帯番号・または連絡可能な電話番号 ⅱ） Sponsor in India :　観光ビザ以外の場合はインド受け入れ先の会社名、担当者名、住所、電話番号 NONE (該当がない場合） 29. I confirm that all the information stated is accurate. I undertake to utilize my visit to India for the purpose for which the visa has been applied for and for that purpose only. The visa fee paid is non refundable. 上記の内容は、真実且つ正確であり、このビザ申請内容の目的でインドを訪問することに同意します支払い済みのビザ申請料金は返金されません Date: 24 MAR 2011(申請日） Place: TOKYO JAPAN (Signature) （署名SIGNATUREに関しての注意）　パスポートと同じ署名パスポート所持者直筆サインのみ認めます結婚などにより　パスポート姓名訂正後の場合もパスポート作成時の署名をして下さい。署名が漢字の場合は同様に漢字署名をして下さい。山田華子 PHOTO 3.5 cm x 4.5 cm EMBASSY OF INDIA TOKYO APPLICATION FORM FOR VISA FOR INDIA APPLICANTS SHOULD NOTE THAT IF ANY RELEVANT INFORMATION IS WITHHELD OR IS GIVEN INCORRECTLY, THE VISA IS LIABLE TO BE REFUSED OR, IF ALREADY ISSUED, TO BE CANCELLED 1. Type of visa required (please encircle): Tourism / Business / Diplomatic / Official / Employment / Project / Journalist / Medical / Research / Student / Transit / Entry / Conference (Journalists must apply for ‘J ’ visas only, irrespective of official or private visits) 2. Period, in months, for which visa is required: 3. Number of entries required: Single / Double / Multiple 4. Present Nationality of the applicant: 5. Full Name : Mr. / Mrs / Miss 6. Previous Name, if any: Mr. / Mrs / Miss 7. Father's / Husband’s Name: Mr. 8. Permanent Address: 9. Present Address, Phone number & Email: 10. Profession / Occupation along with name of Company/ address / phone number: 11. Passport particulars: Passport Number: Date of Birth: Date of issue: Place of Birth: Date of Expiry: Place of issue: 12. Details of previous visit(s) to India, if any: 13. Whether visa or extension of stay in India has been refused previously? 14. If so, give details 15. Detailed purpose of present visit and places to be visited: 16. Expected date of departure from Japan: 17. Expected date of Entry in India: 18. Port of entry in India: 19. Name of destination country (for transit visas): 20. Expected date and port of departure from India: 21. Name, phone and address of two references: ⅰ） Japan : ⅱ） India : 22. Whether the applicant or his/her parents or grandparents (both paternal and maternal) were holding the nationality of Pakistan at anytime 23. Countries visited during the last 10 years: 24. Whether present citizenship has been acquired by birth or naturalization 25. Citizenship of any other country held previously 26. The address of friends / relatives / places of stay during the previous travel to India 27. From where visa(s) was / were acquired during previous visit(s) to India 28. Telephone and mobile numbers: ⅰ） Applicant : ⅱ） Sponsor in India : 29. I confirm that all the information stated is accurate. I undertake to utilize my visit to India for the purpose for which the visa has been applied for and for that purpose only. The visa fee paid is non refundable. Date: Place: (Signature)