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UMSOKNAREYDUBLAD FYRIR VEGABREFSARITUN / VISA APPLICATION FORM

EMBASSY OF INDIA, SKULAGATA 17, 101 REYKJAVIK, ICELAND EMAIL: GEN@INDIANEMBASSY.IS

FYLLA THARF EYDUBLAI UT A ENSKU NEMA UPPLYSINGAR FRA PASSA. AD UTFYLLINGU LOKINNI ER SMELLT A "SAEKJA PDF" OG ER THAD SKJAL PRENTAD UT. / PLEASE COMPLETE THIS APPLICATION FORM ONLINE. REMEMBER TO PRINT THE PDF FILE AND SIGN IT BEFORE SUBMISSION. OFULLNAEGJANDI UTFYLLT UMSOKN VERDUR EKKI TEKIN GILD. ADUR EN UMSOKN ER UTFYLLT, VINSAMLEGAST LESID ARIDANDI UPPLYSINGAR SEM ERU NEDST A BLADSIDUNNI VANDLEGA / INCOMPLETE APPLICATION FORMS WILL NOT BE ACCEPTED. BEFORE FILLING THIS FORM, PLEASE READ IMPORTANT NOTE GIVEN AT THE BOTTOM OF THE PAGE CAREFULLY.

TITILL / TITLE: MR FODURNAFN / SURNAME: KJARTAN J SKIRNARNAFN / GIVEN NAMES : RUBNER FRIDRIKSSON FULLT NAFN GEFID VID FAEDINGU (EF ANNAD EN NUVERANDI) / FULL NAME AT BIRTH (IF DIFFERENT FROM ABOVE): KJARTAN JNATAN FRIRIKSSON FODURNAFN / SURNAME: KJARTAN J FAEDINGARDAGUR / DATE OF BIRTH : 16-01-1979 FAEDINGARSTADUR (BAER OG LAND) / PLACE OF BIRTH (TOWN & COUNTRY) : REYKJVIK ICELAND NUVERANDI THJODERNI (EINNIG SKAL TILGREINA HVORT THJODERNI SE VID FAEDINGU EDA UPPTOKU RIKISFANGS) / PRESENT NATIONALITY (ALSO STATE WHETHER ACQUIRED BY BIRTH OR BY NATURALISATION) : ICELANDIC VID FAEDINGU EDA UPPTOKU / BY BIRTH OR NATURALISATION: BY BIRTH HEFUR THU HAFT ANNAD THJODERNI? / HAVE YOU EVER HELD ANOTHER NATIONALITY? : NO EF JA, FYLLID UT EFTIRFARANDI / IF YES, GIVE FOLLOWING DETAILS : HVORT UMSAEKJANDI, FORELDRAR, FODUR- EDA MODURFORELDRAR HAFA HAFT RIKISFANG FRA PAKISTAN EITTHVERN HLUTA AEVINNAR / WHETHER THE APPLICANT OR HIS PARENTS OR GRANDPARENTS (BOTH PATERNAL AND MATERNAL) WERE HOLDING THE NATIONALITY OF PAKISTAN AT ANY TIME: NO EF JA, SKILGREINID HVENAER / IF YES, GIVE DETAILS : VEGABREFSNUMER / PASSPORT NO. : A2189306 UTGAFUDAGUR / DATE OF ISSUE : 21-07-2010 GILDISTIMI / DATE OF EXPIRY : 21-07-2015 VEGABREF UTGEFID AF / PASSPORT ISSUED BY (AUTHORITY/AGENCY) : THJODSKRA ISLANDS STADUR / LAND UTGAFU / PLACE/COUNTRY OF ISSUE : REYKJAVIK ICELAND UPPLYSINGAR UM ANNAD GILT VEGABREF I NOTKUN / DETAILS OF ANY OTHER VALID PASSPORT PRESENTLY HELD: NONE ERLEND KENNITALA / FOREIGN NATIONALITY ID : NONE KYN / SEX :

KARLKYN / MALE ATVINNA / OCCUPATION : IT CONSULTANT NAFN VINNUVEITANDA/FYRIRTAEKIS/STOFNUNAR / NAME OF EMPLOYER / COMPANY / FIRM : EC HUBUNADUR EHF HEIMILISFANG SKRIFSTOFU / OFFICE ADDRESS : ADALSTRAETI 6 POSTFANG / POSTCODE: 101 REYKJAVK LOGHEIMILI / PERMANENT ADDRESS : SKELJAGRANDI 5 POSTFANG / POSTCODE: 107 REYKJAVK DVALARHEIMILI / PRESENT ADDRESS : SKELJAGRANDI 5 POSTFANG / POSTCODE: 107 REYKJAVK SIMANUMER / TELEPHONE NO.: 8635070 FARSIMANUMER / MOBILE: 8635070 TOLVUPOSTFANG / E-MAIL ADDRESS : KJARTANF@GMAIL.COM UMSAEKJANDI THARF AD UTFYLLA THENNAN HLUTA AD FULLU / APPLICANT MUST COMPLETE THIS SECTION NUVERANDI FAEDINGARSTADUR / THJODERNI / PLACE OF BIRTH PRESENT NATIONALITY NAFN FODURS / FATHER'S NAME NAFN MODUR / MOTHER'S NAME NAFN MAKA / SPOUSE'S NAME FRIDRIK ADOLFSSON ICELAND MIRIAM RUEBNER STEINUNN JONSDOTTIR ISRAEL ICELAND ICELANDIC ICELANDIC ICELANDIC FYRRA THJODERNI / PREVIOUS NATIONALITY ICELANDIC ISRAEL ICELANDIC

HEFUR VEGABREFSARITUN ADUR VERID NEITAD? / WHETHER VISA WAS REFUSED EARLIER NO EF JA, TILGREINID ASTAEDU / IF YES, GIVE DETAILS HEFUR THU HEIMSOTT INDLAND ADUR? / HAVE YOU VISITED INDIA EARLIER? YES EF JA, STADI OG DAGSTENINGAR / IF YES, GIVE DETAILS CHENNAI A NUMBER OF TIMES, LAST TIME IN JAN 2010 HVADAN VAR VEGABREFSARITUN FENGIN FYRIR FYRRI HEIMSOKNIR / FROM WHERE THE VISA WAS ACQUIRED DURING PREVIOUS VISIT(S) INDIAN EMBASSY IN ICELAND AND INDIAN EMBASSY IN HAAG HEIMILISFONG VINA/AETINGJA/STADA FYRRI FERD(A) TIL INDLANDS / ADDRESSES OF FRIENDS/RELATIVES/PLACES OF STAY DURING PREVIOUS TRAVEL(S) TO INDIA T. SENTHIL KUMAR, NO.1, EAST PARK ROAD, SHENOY NAGAR CHENNAI 600 030. ONNUR LOND SEM THU HEFUR HEIMSOTT SIDUSTU TIU AR / COUNTRIES VISITED DURING THE LAST TEN YEARS HOLLAND, USA, ISRAEL, DENMARK, SWEDEN, FRANCE, GERMANY, SWISS TILGANGUR NUVERANDI FERDAR TIL INDLANDS / PURPOSE OF THE CURRENT VISIT TO INDIA VIDSKIPTAFERD / BUSINESS / EF ANNAD, VINSAMLEGA SKILGREINID / IF OTHER, PLEASE SPECIFY HVE LENGI AETLAR THU AD VERA I INDLANDI? / HOW LONG DO YOU INTEND TO STAY IN INDIA? : 10 DAYS FJOLDA FERDA INN I LANDID / NUMBER OF ENTRIES REQUESTED MARGNOTA / MULTIPLE DAGSETNING / DATE OF A) BROTTFOR FRA ISLANDI / DEPARTURE FROM ICELAND : 24-03-2012 B) KOMA TIL INDLANDS / ARRIVAL IN INDIA: 25-03-2012

C) BROTTFOR FRA INDLANDI / DEPARTURE FROM INDIA : 03-04-2012 FYRSTA BORG VID KOMU TIL INDLANDS / FIRST CITY OF ARRIVAL IN INDIA : CHENNAI ADRIR STADIR SEM HEIMSAEKJA SKAL A INDLANDI / OTHER PLACES TO BE VISITED IN INDIA NAFN, HEIMILISFANG, SIMANUMER OG FARSIMANUMER HJA THEIRRI PERSONU/STUDNINGSADILA SEM THU ERT AD FARA AD HEIMSAEKJA / NAME, ADDRESS, TELEPHONE AND MOBILE NUMBER OF THE PERSON / SPONSOR WHO YOU WILL BE VISITING SIMANUMER / FARSIMANUMER NAFN / NAME HEIMILISFANG / ADDRESS TELEPHONE / MOBILE NO. NO. T. SENTHIL KUMAR NO.1, EAST PARK ROAD, SHENOY NAGAR CHENNAI 600 030. 91 44 42182941 91 9677157766

ERU EINHVER BORN AD FARA MED SEM ERU EINNING I VEGABREFI UMSAEKJANDA / WHETHER ANY CHILDREN ACCOMPANYING THE APPLICANT ARE INCLUDED IN HIS/HER PASSPORT NO EF JA, FYLLID UT EFTIRFARANDI / IF YES, GIVE FOLLOWING DETAILS NAFN / FAEDINGARSTADUR / FAEDINGARDAGUR / KYN / SKYLDLEIKI / NAME PLACE OF BIRTH DATE OF BIRTH SEX RELATIONSHIP AUDKENNI (EF EITTHVAD) / IDENTIFICATION MARK (IF ANY)

TVEIR TENGILIDIR SEM HAEGT ER AD HAFA SAMBAND VID EF NAUDSYN KREFST / TWO REFERENCES WHO COULD BE CONTACTED IN CASE OF NEED SIMANUMER / NAFN / NAFN HEIMILISFANG / ADDRESS TELEPHONE NO. A ISLANDI / IN ICELAND 1. 2. MIRIAM RUEBNER STEINUNN JONSDOTTIR SKELJAGRANDI 5 BALDURSGATA 26 NO.1, EAST PARK ROAD, SHENOY NAGAR CHENNAI 600 030. SIVANANDHAM BUILDINGS NO.1, EAST PARK ROAD SHENOY NAGAR CHENNAI 600 030. 8205585 6180440 91 9677157766 91 98400 37933

A INDLANDI / IN T. SENTHIL 1. INDIA KUMAR 2. M. HARISH

ATH: ARITUN ER GILD FRA UTGAFU. ATHUGADU HVORT THU HAFIR GILDA ARITUN ADUR EN SOTT ER UM NYJA. / NOTE THAT VISA IS VALID FROM DATE OF ISSUE. CHECK IF YOU ALREADY HOLD A VALID VISA BEFORE APPLYING

YFIRLYSING / DECLARATION EG / I , KJARTAN FRIDRIKSSON STADFESTI HER MED AD EG MUN EINGONGU VERA AD FARA I THEIM TILGANGI SEM ARITUNIN TILGREINIR, OG EG MUN EKKI REYNA AD FRAMLENGJA ARITUNINNI TIL INDLANDS AD ODRUM KOSTUM. EG STADFESTI EINNIG AD VERA BUSETUR A ISLANDI THEGAR EG SAEKI UM ARITUNINA OG AD ALLAR UPPLYSINGAR SEM EG HEF GEFID UPP ERU SANNAR, NAKVAEMAR OG FULLNAEGJANDI / HEREBY UNDERTAKE THAT I SHALL UTILISE MY VISIT ONLY FOR THE PURPOSE FOR WHICH VISA HAS BEEN APPLIED, AND SHALL NOT ON ARRIVAL IN INDIA TRY TO EXTEND MY STAY FOR ANY OTHER PURPOSE. I ALSO DECLARE THAT I AM PRESENT IN ICELAND ON THE DATE OF MAKING THIS APPLICATION AND THAT ALL THE INFORMATION GIVEN HERE BY ME IS TRUE, ACCURATE AND COMPLETE DAGSETNING / DATE: 21-03-2012 UNDIRRITUN UMSAEKJANDA / SIGNATURE OF APPLICANT : SKORTUR A UPPLYSINGUM OG MISVISANDI/RANGAR UPPLYSINGAR MUNU HAFA THAER AFLEIDINGAR AD VIDKOMANDI GAETI VERID NEITAD UM ARITUN AN UPPGEFNAR ASTAEDU. GJALD FYRIR ARITUN ER EKKI ENDURKROFUHAEF OG GAETI BREYST FYRIRVARALAUST. EFTIR AD ARITUN HEFUR VERID FENGIN SKAL TRYGGJA AD NAFN, STAFSETNING, VEGABREFSNUMER, TEGUND OG GILDISTIMI ARITUNAR SEU RETTAR. EINNIG SKAL ATHUGA AD ARITUN HEFUR HRINGSTIMPIL OG ER ARITAD AF STARFSMANNI SENDIRADSINS. / SUPPRESSION OF FACTS OR FURNISHING MISLEADING/FALSE INFORMATION WILL RESULT IN DENIAL OF VISA WITHOUT ASSIGNING ANY REASON. VISA FEE ONCE TENDERED IS NON-REFUNDABLE AND SUBJECT TO CHANGE WITHOUT NOTICE. AFTER RECEIPT OF VISA ENSURE NAME, SPELLINGS, PASSPORT NUMBER, TYPE AND VALIDITY OF VISA ARE GIVEN CORRECTLY. ALSO VISA BEARS ROUND STAMP AND IS DULY SIGNED BY THE VISA OFFICER. UTFYLLIST AF SKRIFSTOFU / FILLED OUT BY OFFICE VISA NO.: DATE OF ISSUE: DATE OF EXPIRY: TYPE OF VISA: RECEIPT NO.: