APPLICATION FORM

( Exit Permit )

260123356F0Z

Application ID No. 260123356F0Z Final Submission Date Thu Jan 26 19:36:42 IST 2023

FOR OFFICE USE ONLY

Reg. No. B 0 0 1 T H A 2 0 2 3

Personal Details
Surname MATTAPURT
Given Name MISS ROTJANA Paste your
Sex Female Date of Birth 31/01/1997 Height (in cm) 150 Recent passport size
Age as on today Year(s) 25 Month(s) 11 Day(s) 26 photograph here
Place of Birth NONG YAI, SATUK, BURI RAM, 31150.,BURI RAM,THAILAND
Father's Name JUAN KO SO NOEN
Mother's Name RAMPEY MATTAPURT
Spouse's Name
Religion BUDDHISM Any Identification mark(s) preferably NO
visible

Present nationality THAILAND Previous nationality

Manner of acquiring present nationality Birth
Date of acquiring present nationality
Whether holding dual NO
nationality? If yes, Name of the country of second nationality
provide the following:- Passport No. of second country
Date of Issue
Date of Expiry
Whether travelled on this passport earlier to
India

Whether person of Indian Origin NO

Address of last residence (Outside India)

Address 164/2 NONG YAI
City SATUK Country THAILAND

Address intended for longer stay in India (Registration)

Address BHOGAL BUDDHA VIHAR JANGPURA
City/ District DELHI State DELHI
Pin Code 10014
Phone Number Mobile Number 9958228779
Any Other Address in India
Address
City/ District State
Pin Code
Phone Number Mobile Number
Email/Occupation/Profession Details
E-Mail Id Kamonnopk@gmail.com
Profession/Occupation WORKER

Passport Details
Passport Number AC4216723 Place of Issue THAILAND, BANGKOK
Date of Issue 24/11/2022 Expiry Date 23/11/2027

Visa Details
Visa Number 1004V84C5522 Place of Issue THAILAND, BANGKOK
Date of Issue 29/11/2022 Expiry Date 28/11/2023
Valid For Single Entry Visa Type TOURIST VISA
Special endorsement, if any

Organization/Company/Institute/Hospital Details
Name
Address

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 260123356F0Z
Application ID No. 260123356F0Z

State City
Telephone Number Email ID
Employer EPFO ID Establishment ID
Arrival Details
Place of embarkation/boarding for India MUMBAI,MUMBAI,THAILAND
Date of arrival in India 30/11/2022
Place of disembarkation/arrival in India MUMBAI AIRPORT
Mode of Journey Air Flight/ Ship/ Bus/ Train No. AIRCRAFT32A
Purpose of visit to India Tourism

Previous Registration Details in India

Registration Number Place of Registration Visa Type Duration From To
Details of family members/attendant/dependents, if any accompanying.
Name Nationality Passport Number Relationship
Person to be contacted in Case of Emergency
Name NIRAN CHUEACHIT Relationship ASSITANT OF PRESIDENT
Address BHOGAL BUDDHA VIHAR City DELHI
Country INDIA Phone Number 10014
Category Others

Military service details

Organisation Designation
Rank Place of Last Posting
Country of Last Posting

Current Registration Details

Are you registered in current locality FRRO/FRO in the current visit? YES Current 260123356FOZ
Registration No.

Exit Permit Details

Departure Date 31/01/2023
Expected exit in Days 5
Reason of Delay WAITING FRRO

Signature of the Applicant

Date_ _ _ _ _ _ _ _ _ _ _ _ _

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Application ID No. 260123356F0Z

List of mandatory and non mandatory documents

Mandatory Documents.
1. Photo : Applicant's Photo
2. Passport and Visa : Photo Page, Page indicating validity, Page bearing arrival stamp of Indian Immigration, Visa Page (Lost Passport)----if available
3. Residence proof : Copy of Form C from Hotel or Lodge OR Electricity bill / Landline Telephone / Municipal Bill of the landlord along with a letter and photo-ID card of the landlord OR
Rent/Lease Agreement OR letter from educational Institution confirming accommodation in the hostel

4. RC/RP : RC/RP (Registration Certificate/Residential Permit—if any

5. Tenant Verification : Verified/Stamped copy of Tenant Verification Form from jurisdictional Police Station (in case of rented accommodation)
6. FIR : Copy of FIR mentioning Passport No. which was reported lost
7. New Passport : Copy of new Passport/travel document
8. Embassy letter : Letter from concerned embassy mentioning loss and subsequent issue of Passport/ Travel Document

Registration office address

Office Name : FRRO NEW DELHI

Address : EAST BLOCK 8, SECTOR 1 , R.K. PURAM, NEW DELHI
City/District : DELHI
State : DELHI
Pin Code : 0
Phone Number : 01126711443

Office opening time: 9.30 closing time: 18.00

There is no need to submit hard copy to concerned

FRRO/FRO

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