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
mongkolyanathum@gmail.com
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:

Page 3 of 3

17.00