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Visa Application Form

Signature
LKAC06421622

A. Personal Particulars (As in Passport)

Surname (As in Passport) JAYASEKARA MUDIYANSELAGE
Application Id : LKAC06421622

Given Name (As in Passport) RUVINI NISANSALA JAYASEKARA

Previous/other Name if any Not Applicable
Gender FEMALE Marital Status SINGLE
Date of Birth 30-JUL-2000 Religion BUDDHISM
Place of Birth Town/City PERADENIYA Country of Birth SRI LANKA
Citizenship /National ID No 200071200627 Educational Qualification HIGHER SECONDARY
Visible identification marks NA
Current Nationality Nationality by Birth/
SRI LANKA Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. N9891695 Date of Issue ( dd/mm/yyyy ) 06-SEP-2022
Place of Issue COLOMBO Date of Expiry ( dd/mm/yyyy ) 06-SEP-2032
Web Registration Date : 08-SEP-2022

Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of Issue Place of Issue
Passport/IC No. Date of issue (dd/mm/yyyy)
Nationality/Status
C. Applicant's Contact Details
NO 100/44, PARAKUM LANE,
Present SALIYA MW Phone No
Address ANURADHAPURA Mobile /Cell No 94716561777
NORTH CENTRAL, SRI LANKA JAYASEKARAPREMATHILAKA@GMAIL.C
50000 Email address OM

NO 100/44, PARAKUM LANE,

Permanent SALIYA MW
Address ANURADHAPURA
NORTH CENTRAL

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
JAYASEKARA MUDIYANSELAGE ANURADHAPURA
Father's PREMATHILAKA SRI LANKA SRI LANKA
J M PUSHPA NIRANGIKA KANDY
Mother's JAYASUNDARA SRI LANKA SRI LANKA
Marital
Status Single
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

RUVINI NISANSALA JAYASEKARA JAYASEKARA MUDIYANSELAGE

E. Details of Visa Sought (Visa shall be valid from the Date of Issue and not from the Date of Journey)
Type Of Visa Required STUDENT VISA No of Entries MULTIPLE
Period of Visa ( Month) 36 Month Expected Date of Journey 28-SEP-2022
Port Of Arrival ALL PORTS Port of Exit ALL PORTS
Required Detail of STUDENT VISA
Institution BESANT WOMENS COLLEGE
Address M.G. ROAD, KODIALBAIL, MANGALURU
Phone +917259836645
Email
Course Detail BACHELOR OF FOOD NUTRITION AND DIETETICS
Duration 3 YEARS
Purpose of Visit : FOR HIGHER EDUCATION (INCLUDING IN SOUTH ASIAN UNIVERSITY AND NALANDA
UNIVERSITY) , PROVISIONAL STUDENT VISA, FOR SHORT TERM COURSES AND FOR THOSE COMING UNDER
STUDENT EXCHANGE PROGRAMME
F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India ,

Application Id : LKAC06421622
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10
years
Have you been refused an Indian Visa or extension of the same previously or deported
from India ? NO
G. Profession/Occupation Details : of Father
Present Occupation STUDENT Designation/Rank
Employer name/business POLICE DEPARTMENT
Employer Address
Phone Number HEADQUARTERS POLICE, ANURADHAPURA
Past occupation if any
Are/have you worked with Armed forces/ Police/ Para Military forces ? NO
Organization Designation
Place of Posting Rank
H. Details of Two Reference
In India In SRI LANKA
Name DR. SATHISH SHETTY J M PREMATHILAKA
Address BESANT WOMENS COLLEGE NO 100/44, PARAKUM LANE,
M.G. ROAD, KODIALBAIL,
MANGALURU SOUTH
KANNADA KARNATAKA SALIYA MAWATHA, ANURADHAPURA
Phone Number +917259836645 +94718042702
J. DECLARATION
a. I do not hold any other passport(s) other than those detailed above.
b. I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them.
c. I declare that the information given in the form is complete and correct and the visit to India will be undertaken for the purpose
indicated in the application.
d. I understand that in case the information provided in the form is found to be incorrect, I will be liable for denial of visit/ entry or
deportation and/ or other penalties during the visit as provided by Indian law.
e. I will also submit hard-copy all the uploaded documents along with the print of application to submit to the concerning Indian
Mission or Agency for processing of visa application.

08-SEP-2022 ................................
Date : ...................... Applicant's signature (as in Passport)