JABATAN IMIGRESENMALAYSIA

BORANG PERMOHONANVISA
VISA APPLICATION FORM

1M.47- Pin. 1/97

*Jenis Permohonan
Type of Application
Dalam Malaysia
In Malaysia D Seberang Laut
Oversea D
Gambar
Pemohon
A. MAKLUMAT PEMOHON
PhotographOf
PARTTCTTTARS OF APPUCANT
Applicant
1. Nama Penuh(Huruf Besar) (3.5 em x 5.0
Full Name (CapitalLetter) em)
VIKRAM SINGH RATHORE
I

2. *Jantina
Gender
Lelaki
Male D M Perempuan
Female D
3. TempaUNegaraLahir
Place/Country of Birth [ MUMBAI INDIA ]
INDIAN
[ 11 OCT 1965
4. **Tarikh Lahir 5. Warganegara
Date of Birth Nationality
hari bulan tahun
day month year
6. Pekerjaan
INVESTMENT BANKER
Occupation

7. Alamat
Address 2010,BREEZE COOPERATIVE HOUSING SOCIETY,MANAV NAGAR, JAI PRAKASH
NAGAR ANDHERI WEST MUMBAI 400058

.
8. Taraf Perkahwinan
Marital Status
Belum Berkahwin
Single D X
Berkahwin
Married D
B. MAKLUMAT PASPORT PERJALANAN J DOKUMENPERJALANAN
PARTTt?llTARS OF PASSPORT / TRA VRT.J)Ot?llMF.NT

9. Jenis Dok.umen Perjalanan

PASSPORT
10. Nombor Z00052336
Type Of Travel Document Number

MUMBAI INDIA
11. Tempatl Negara DiKeluarkan
Place/ Country Of Issue
[ 12. **Sah
ValidSehingga
Until [ 12 FEB 2020
hari bulan tahun
day month year

. Borang ini hendaklah ditaip. Tandakan (x) dalam petak yimg berkenaan. .. Format T arikh 99/99/9999
Date Format DD/MM/YYYY
This form should be typed. Mark (x) in the appropriate box.
c. BUTIR-BUTIR PENGANJUR DI MALAYSIA
PARTlClTTARS OP SPONSOR IN MAlA Y.~lA

13. Nama Penuh ( Huruf Besar)

Ful Name(Capital Letter)
[ Name of Business Counterpart [Incase of Business Visa]
[Name of the Hotel] if available or can be left blank if not available for Tourist Visas
15. No Telefon
if available [only for Business]
14. NO.KadPengenalan
NRIC ] Telephone No. [
[Address of the Business Counterpart or Address of the Hotel [as per Category of Visa]
16. Alamat
Address

Negeri
State

D. BUTIR~BUTIR PERMOHONAN
UP-TATT.OF APPUCATTnN

17. Tempoh Tinggal Yang Dicadangkan Bulan

Duration Of Proposed Stay Month SEPTEMBER

18. *Tujuan Perjalanan

Purposed Of Journey
Bercuti
Holiday D Transit
Transit D
Urusan PerniagaaR
Business D X
Urusan
Official
Rasmi
Trip D
Melawat Saudara Mara I Kawan
VisitingFriends / Relatives D Persidangan
Conference D
Bekerja
Employment D Lain-lain (Nyatakan)
Other Specify [
Belajar
Study D

Tarikh Tandatangan Pemohon I Penganjur

Date [Date of Application] Signature of Applicant / Sponsor [Signature as per your Passport]

. Borang ini hendaklah ditaip. Tandakan (x) dalam petak yang berkenaan. .. Format Tarikh 99/99/9999
This form should be typed. Mark (x) in the appropriate box. Date Format DD/MMIYYYY