APPENDIX XXII

                                                                    Para 139(1)

 

                                         GOVERNMENT OF INDIA

                                     MINISTRY OF HOME AFFAIRS

 

 

                      REQUEST FOR SPECIAL PERMIT FOR PROTECTED AREAS

                                         (Application to be submitted in duplicate)

 

 

 

 

 

    Photograph

 

 

 

     1. Name of the Applicant: ________________________________________________

         (in capital letters with Surname underlined)

 

     2. Father’s Name: ______________________________________________________

 

  3. Honorifics: Mr./Miss/Mrs. ______________________________________________

      (Score out those not applicable)

 

    4. Surname at birth, if different: ____________________________________________

 

    5. Place and date of Birth: ________________________________________________

        (Your Town and Country)

 

    6. Nationality: (a) Present ________________________________________________

                           (b) Past, if different, till which date ______________________________

                           (c) Reason for change________________________________________

 

    7. Occupation: _________________________________________________________

        (Give address of place of work if employed)

 

    8. Permanent Address: _______________________________­­­­­­­___________________

 

    9. Mailing address in India, if any: __________________________________________

 

  10. Reference (a) In country of applicant _____________________________________

                          (b) In India _________________________________________________

 

 

  11. Passport Details: No: __________________________________________________

                         Issued by: __________________________________________________

                                       At______________________ valid up to ___________________

 

  12. Details of visa for India if any obtained:

                                                      Issued by:____________________________________

                                                        Number_____________________________________

                                                                 At ____________________________________

                                                    Valid up to ____________________________________

 

 13. Places proposed to be visited: ___________________________________________

 

 14. Route intended to be followed: ___________________________________________

 

 15. Purpose of visit: ______________________________________________________

 

 16. Likely date of visit: ____________________________________________________

 

 17. Likely duration of visit: _________________________________________________

 

 18. Is anyone accompanying the applicant?

       If so, give details: _____________________________________________________

 

 19. Arrangements for travel and accommodation that may have been made.

        ___________________________________________________________________

 

 20. Details of previous visits to India: _________________________________________

 

 21. Has/have He/She/They previously visited any Restricted / protected area in India

       or Bhutan?

       If so, please give details of the places visited and date of visit.

 

        ___________________________________________________________________

 

 22. Has any earlier request for permit been refused? If so, please furnish details.

        ___________________________________________________________________

 

 

                                                       -:DECLARATION:-

 

       The information given above is correct and complete to the best of my knowledge

 

        Place_______________________

 

        Date________________________                         Signature of Applicant

 

 

 NOTE :-   1. This application is to be sent to the Ministry of Home Affairs, New Delhi.

                 2. It is advisable to make the application at least eight weeks ahead of the

                     date of the proposed visit.

                 3. Applicants outside India are expected to route their application

                      through the nearest Indian Diplomatic or Consular Mission.