ࡱ> MOL'` bjbj{P{P .*::%O.RRR8,.7("   6666666$8hj:L6|6  6333^8  636333hu6  ̂ԌR 5$660715D::Hu6:u6 3yt66^7...$R...R...  INCLUDEPICTURE "http://www.cgitoronto.ca/images/ashoka.jpg" \* MERGEFORMATINET   SHAPE \* MERGEFORMAT  HIGH COMMISSION OF INDIA 10, Springfield Road, Ottawa, Ontario, K1M 1C9 Telephone: 613-744 3751; Fax: 613 744 0913 APPLICATION FORM FOR PERSONS OF INDIAN ORIGIN (PIO) CARD (a) Name of the applicant: ______________________________________ (b) Surname at birth: ___________________ (c) Other names:_______________________ (d) Date of birth: ______________________ (e) Place of birth: (town, city, country): _________________________ 2. Father's/Mother's/Spouse's name & nationality: Father :__________________________Nationality______________ Mother:_________________________ Nationality______________ Spouse:_________________________ Nationality______________ 3. Address: Present:____________________________________________________________________________EMail:__________________Tel No.___________ Permanent: _______________________________________________ ____________________________________________Tel. No. __________ Address in India (verifiable) : ________________________________ ________________________________________________________ 4. Profession:____________________________ 5. Business/Office Address: _____________________________________ ___________________________________________Tel. No. __________ 6. Sex: _______ 7. Marital status: ____________________ 8. Nationality (at the time of birth):______________________ Present nationality (if different):____________________ Date on which acquired:__________________________ 9. Passport particulars of applicant: Passport Number :_______________(b) Place of Issue :____________ Date of Issue: __________________(d) Date of expiry:____________ (e)Country which issued the Passport:_________________________ (Please enclose the passport and copy of the first page) 10. Mark of identification:______________________________________ 11. Does the applicant hold dual nationality:_________________________ (If so, please give details including the details of all the passports held etc.) 12. Did the applicant at any time hold the nationality of any country other than present nationality? If so, please give details thereof: ________________________________________________________ 13. Whether the applicant or either of his/her parents or grand parents or great grand parents held an Indian passport at any time, if so details thereof: Passport Number :_______________(b) Place of Issue :____________ Date of Issue: __________________(d) Date of expiry:____________ 14. Whether the applicant or either of his/her parents or any of his/her grand parents or great grand parents was born and was permanently resident in territories falling in present day India, Pakistan, and Bangladesh as on 30.3.1999 and if so the following details may be indicated: Date & Place of birth :_______________________________ Proof of residence etc :______________________________ (Enclose photocopy of relevant documents) (Note: If applicant is the spouse of a citizen of India or a person of Indian origin, his/her particulars should be indicated) 15. Has the applicant ever been refused Indian passport/travel document or visa for visiting India? If so, give complete details (i.e. place & date of application, purpose, reasons for refusal, etc): 16. Name & complete addresses of two persons known to the applicant living in India: Name and address:_________________________________________ _________________________+Telephone No. __________________ Name and address:_________________________________________ __________________________Telephone No:__________________ D E C L A R A T I O N I hereby declare that the above statements are true to the best of my knowledge and belief. Signature of the applicant Date:_____________ Two specimen signatures of the applicant : or thumb impression in case of a child       PAGE  PAGE 1 Paste one photo here and attach two more photos of the size 3.5cm X 3.5 cm SVB C } EmnopϰxmmaaYUYh+jh+Ujh+CJUaJh+5>*CJaJh+5CJaJh!NCJaJh+CJ aJ h+CJaJh+>*CJOJQJaJh+OJQJaJh+5>*CJ OJQJaJ j=h+>*OJQJUaJh+>*OJQJaJjh+>*OJQJUaJ)jh+>*OJQJUaJmHnHu! 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