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)
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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.