Select the center as per your jurisdiction.

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1 Select the center as per your jurisdiction. This is not your Applicant ID to track your application on after submission, this is just the temporary ID. State your Social Security Number or state NA in case you do not hold it. Any visible identification mark to be mentioned or None in case there is no visible identification mark

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3 If not same as your current address, it can be the other address in the same Country or Country of your Origin or current Nationality

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5 \ This is not your Applicant ID to track your application on after submission, this is just the temporary ID.

6 Reference details are mandatory. This can be of your tentative hotel booking in India (Strongly recommend not to make any payments towards your hotel reservation before Visa is granted) Photo upload here is not mandatory. However, it is mandatory to affix a photo on the hard copy of form before submitting to us even if you have uploaded the same online.

7 This is not your Applicant ID to track your application on after submission, this is just the temporary ID.

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12 Status of application can be tracked on with this ID only after us receiving the hard copy of application form in Post/In person and further processing is initiated on the same. Take print of the submitted application form and follow instructions as advised in the illustration below

13 Click here to View Photo Specification Visa Application Form Paste your unsigned recent photograph. Size: 2" X 2" Signature/Thumb Impression of applicant only (In case of thumb impression of male use left hand thumb and for female use right hand thumb) USAC Signature Web File Number :USAC Web Registration Date : 26-AUG-2013 A. Personal Particulars (As in Passport) Surname (As in Passport) Given Name (As in Passport) SPENCER DAVID BRIAN Previous/other Name if any Sex Date of birth Place of Birth Town/City Citizenship /National ID No Male 26-MAY-1984 WASHINGTON Marital Status Religion Country of Birth Educational Qualification Married CHRISTIAN UNITED STATES OF AMERICA GRADUATE Visible identification marks SCAR ON FOREHEAD Current Nationality UNITED STATES OF AM Nationality by Birth/ NaturalizationNATURALIZATION Any Other Previous/Past Nationality INDIA B. Passport Details Passport No. A Date of issue ( dd/mm/yyyy ) 01-JUL-2012 Place of issue WASHINGTON DC Date of expiry (dd/mm/yyyy) 01-JUL-2023 Any other Passport/Identity Certificate held (if yes,please fill in the following) NO Country of issue Passport/IC No Nationality/status C. Applicant's Contact Details Present address Permanent Address SUITE I STREET NE WASHINGTON DC, UNITED STATES OF AMERICA SUITE I STREET NE WASHINGTON DC Place of issue Date of issue(dd/mm/yyyy) Phone No Mobile /Cell No address D. Family Details Relation Name Nationality Prev. Nationality Place/Country of Birth Father's Mother's RICHARD SPENCER UNITED KINGDOM UNITED KINGDOM LONDON UNITED KINGDOM LONDON UNITED KINGDOM SARAH SPENCER UNITED KINGDOM UNITED KINGDOM WASHINGTON DC Spouse UNITED STATES OF AMERICA UNITED STATES OF AMERICA JENIFER SPENCER UNITED STATES OF AMERICA Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO 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 TOURIST VISA No of Entries Single Period of Visa (Month) 3 Month Expected Date of Journey 03-SEP-2013 Port Of Arrival DELHI Port of Exit DELHI DAVID BRIAN SPENCER

14 i Required Detail of Places to be Visited TOURIST VISA DELHI MUMBAI Purpose of Visit : TOURISM F. Previous Visit Details Have You Ever visited India? Addr es s w her e You s t ay ed i n India NO, Cities in India Visited Type of Visa Visa Issued Place Countries visited in last 10 years UNITED KINGDOM, GERMANY Visa Number Date of Issue Have you been refused an Indian Visa or extension of the same previously or deported from India? If yes above mention when and by whom with control No/Date G. Profession/Occupation Details Present Occupation UN-EMPLOYED Designation/Rank NA Employer name/business NA Employer Address NA Phone Number Past occupation if any WORKER Are/have you worked with Armed forces/ Police/ Para Military forces? NO Organization Designation Place of Posting Rank H. Address of Place of Stay / Hotel Place/Hotel Name Address of Place / Hotel State Phone No. I. Details of Two Reference In India Name APURVA CHAUDHARY Address COAX AND KINGS 12 LANE, ANDHERI MUMBAI Phone Number DAN SPENCER 12 SUITE KINGSON PLACE WA, In UNITED STATES OF AMERICA J. DECLARATION: a. b. c. d. I do not hold any other passport(s) other than those detailed above. I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them. 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. 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. Date : 26-AUG-2014 Signature/Thumb Impression of applicant only (In case of thumb impression of male use left hand thumb and for female use right hand thumb).. Applicant's signature (as in Passport) In case of minor, both parents signature is mandatory in the free area below applicant's signature line (No specific

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Select the center as per your jurisdiction.

Select the center as per your jurisdiction. Select the center as per your jurisdiction. This is not your Applicant ID to track your application on www.blsindia-usa.com after submission, this is just the temporary ID. State your Social Security Number

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