CONSULATE GENERAL OF INDIA MEDAN

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Visa Application Form

Signature
IDNMV001DE22

A. Personal Particulars (As in Passport)

Surname (As in Passport)
Application Id : IDNMV001DE22

Given Name (As in Passport) FITRIYA

Previous/other Name if any Not Applicable
Gender FEMALE Marital Status MARRIED
Date of Birth 28-NOV-1971 Religion ISLAM
Place of Birth Town/City MEDAN Country of Birth INDONESIA
Citizenship /National ID No 1271056811710002 Educational Qualification GRADUATE
Visible identification marks NONE
Current Nationality Nationality by Birth/
INDONESIA Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. C2815148 Date of Issue ( dd/mm/yyyy ) 22-JAN-2019
Place of Issue POLONIA Date of Expiry ( dd/mm/yyyy ) 22-JAN-2024
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Web Registration Date : 12-SEP-2022

Country of Issue Place of Issue

Passport/IC No. Date of issue (dd/mm/yyyy)
Nationality/Status
C. Applicant's Contact Details
Present JL. PEPAYA NO. 2D Phone No 081375329885
Address MEDAN Mobile /Cell No 6281375329885
NORH SUMATERA, INDONESIA
20114 Email address FITRIA9885@GMAIL.COM

Permanent JL. PEPAYA NO. 2D

Address MEDAN
NORH SUMATERA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
MEDAN
Father's SABARUDDIN INDONESIA INDONESIA INDONESIA
MEDAN
Mother's YOHANI INDONESIA INDONESIA INDONESIA
MEDAN
Spouse SUPRAYITNO INDONESIA INDONESIA INDONESIA
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

FITRIYA
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 MEDICAL VISA No of Entries SINGLE
Period of Visa ( Month) 1 Month Expected Date of Journey 20-SEP-2022
Port Of Arrival INDIRA GANDHI Port of Exit INDIRA GANDHI
Required Detail of MEDICAL VISA
Hospital Name ARTEMIS HOSPITALS
Address SECTOR 51, GURUGRAM-122001, HARYANA, INDIA
Doctor Name VIPUL NANDA
Phone/Fax +918657803314
Details ONE
Purpose of Visit : FOR PATIENTS
F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India ,
Cities in India Visited
Type of Visa Visa Number

Application Id : IDNMV001DE22
Visa Issued Place Date of Issue
Countries visited in last 10
years MALAYSIA, SAUDI ARABIA
Have you been refused an Indian Visa or extension of the same previously or deported
from India ? NO
G. Profession/Occupation Details : of Spouse
Present Occupation HOUSE WIFE Designation/Rank NOTARIS SUPRAYITNO
Employer name/business NOTARIS DR SUPRAYITNO SH MKN
Employer Address JL AMIR HAMZAH NO 11 SEI AGUL MEDAN
Phone Number +628116352959
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 INDONESIA
Name PUJA CHATTERJEE SUPRAYITNO
Address ARTEMIS HOSPITALS KANTOR NOTARIS SUPRAYITNO
SECTOR 51, GURUGRAM-
122001, HARYANA, INDIA
GURGAON HARYANA JL. T. AMIR HAMZAH NO 11 MEDAN
Phone Number +911244511111 +628116352959
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.

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