Embassy of India,

Buitenrustweg 2,
2517 KD, The Hague,
The Netherlands.
Tel No.0031-703469771
FaxNo.0031-703562523
E-mail: consular@indianembassy.nl

APPLICATION FORM FOR MISCELLANEOUS CONSULAR SERVICES

Service required: Life Certificate, NRI Certificate, Attestation of document(s), Affix recent
Attestation of Affidavit/Will, Attestation of Power of Attorney, Miscellaneous Passport
Certificates & Others (Please specify)____________ Size
photograph

(Documents required for all kind of services: Two Passport size photographs,
Copy of Passport/PIO/OCI Card, Copy of Residence Permit, Copy of pension
book for Life Certificate. Copy of Marriage Certificate, Address proof in India
and in The Netherlands wherever applicable.

1. Full Name (in Capital Letter)_____________________________________________________

2. Date of Birth___________________3. Place of Birth_________________________________

4. Name of Father________________________5. Name of Mother_______________________

6. CURRENT Passport Particulars: Passport No.:________________ Place of Issue________________

Date of Issue____________________ Date of Expiry____________________

7. Educational qualification_______________________8.Profession______________________

8. Name of spouse______________________________
Present nationality of spouse_______________________ Previous nationality_____________
9. Address & telephone No. in The Netherlands_______________________________________

__________________________________________________________________________

10. Address & Telephone No.in India______________________________________________

__________________________________________________________________________

I____________________________________________, solemnly declare that the information given

above is correct and nothing has been concealed and I am aware that it is an offence to knowingly
furnish false information or suppress material information.
I have not lost, surrendered or deprived of my Indian citizenship and I am not in possession of any
other passport or travel documents (applicable for Indian Passport holders).

Place: The Hague

Date:___________ Signature of the Applicant

Name ___________________