Additional Particulars Form (Page 3 of 3) in pdf

Additional Particulars Form Page 3

12) Has the applicant been convicted for any criminal offense or is currently facing criminal

charges in any court of law?

Yes: Please specify details:

________________________________________________________________________

13) Has the applicant ever applied for asylum?

Yes: Please specify details:

________________________________________________________________________

DECLARATION

I hereby declare that the above particulars are true. I also agree that in case any false

information is given in the above form, appropriate action as per Government of India rules and

regulations may be taken against me, including but not limited to revoking of issued

Visa/OCI/PIO card and any other action as deemed fit by the Government of India or its

agencies.

I am applying for a PIO card (strike off whichever not applicable) (leave blank is applying for visa)

a) As a spouse of an Indian origin person

b) Not as a spouse of Indian origin person

In case of (a), I undertake to intimate the Consulate immediately about the dissolution of such

marriage, if it occurs.

Date: ________ / ________ / ________

Place: ___________________________________ (City, State)

________________________________________

(Signature of the Applicant)

Please note: In case of minor child, both parents/legal guardian should sign the declaration

Additional Particulars Form Page 3