To Khai Thi Thuc

Mẫu (Form) NA1a
Kèm theo Thông tư số 22/2023/TT-

BCA ngày 30 tháng 6 năm 2023
VIET NAM E-VISA APPLICATION FORM

PERSONAL INFORMATION
Full name (as in passport data page ICAO lines; in capital letters)
Passport data page image
Surname: MENARIA Given name: KAILASH CHANDRA
1-2. Sex: 1.3. Date of birth (dd/mm/yyyy): 25/06/1981
Male
Female
Portrait of applicant (recent photo, size 4x6cm, 1.4. Nationality: India 1.5. Place of birth: BATHADA KHURD, RAJASTHAN
jpg/jpeg format, file size ≤ 2 MB, face looking
straight, no hat, no glasses, polite clothes, white 1.6. ID Card number: 1.7. Religion: HINDU
background)
1.8. Have you ever used any other passports to enter into Viet Nam?
Yes No
If “Yes”, please specify
No Passport No Full name Date of birth Nationality
1.9. Do you have multiple nationalities?
Yes No
If “Yes”, please specify the nationalities:
1.10. Violation of the Vietnamese laws/regulations (if any):
Act of violation Time of violation Form of sanction Authority imposed sanction
2. E-VISA REQUEST INFORMATION
2.1. To issue e-Visa for: 2.2. E-Visa duration: 21/11/2024
Single - entry Multiple - entry E- Visa valid from (dd/mm/yyyy): 21/11/2024 to: 18/02/2025
3. PASSPORT INRORMATION
3.1. Passport type:

Passport type
Diplomatic Officials Ordinary Others
If “Others”, please specify:

3.2. Passport number: P6700258 3.3. Issuing Authority/Place of issue:
3.4. Date of issue (dd/mm/yyyy): 14/12/2016 3.5. Expiry date (dd/mm/yyyy): 13/12/2026
Do you hold any other valid passports?
No Yes
If “Yes”, please specify:

Passport type:
4. CONTACT INFORMATION
4.1. Contact address: VPO, BATHADA KHURD, TEH-VALLABHNAGAR, UDAIPUR 313602.
4.2. Current residential address (if contact address is different from current residential address): VPO, BATHADA KHURD, TEH-VALLABHNAGAR,
UDAIPUR 313602.
4.3. Mobile phone number or landline phone number: 9867232289 4.4. Email address: vini97dec@gmail.com
4.5. Emergency contact:

a) Full name: VINI JAIN b) Current residential address: MAHALAXMI CHAMBERS, BHULABHAI
DESAI MARG, MAHALAXMI WEST, BREACH CANDY, CUMBALLA HILL,
c) Telephone number: 02223519714
MUMBAI, MAHARASHTRA 400026
d) Relationship: OFFICE
5. OCCUPATION
5.1. Current occupation:

Businessman Student Employee
Official Others Retired
Unemployed
5.2. Occupation information :

a) Name of Company/Agency/School:
b) Position/Course of study:
c) Address of Company/Agency/School:
d) Telephone number of Company/Agency/School:
6. INFORMATION ABOUT THE TRIP
6.1. Purpose of entry:

Tourist Visiting relatives Working
Business Others
If “Others”, please specify: Tourism

Note:
- According to the provisions of Vietnamese law, foreigners who are investors must have papers proving their investment in Viet Nam in accordance with
the provisions of the Law on Investment; foreigners who work as lawyers in Viet Nam must have a license to practice law in accordance with the Law on
Lawyers; foreigners who enter into Viet Nam to work must have a work permit or a certificate certifying that they are the person who are not required to
have a work permit under the provisions of the Labor Code; foreigners who enter into Viet Nam to study must have a written consent by the Vietnamese
schools or educational institutions; foreigners who engage in religious, journalistic, medical or educational activities must obtain permission from
competent authorities. Foreigners who are residing lawfully in Viet Nam can combine tourism, visiting relatives, medical treatment without having to ask
for permission.
- Foreigners’ activities in Viet Nam must be in accordant with the purposes of their entry.
6.2. Agency/Organization/Individual that the applicant plans to contact when enter into Viet Nam?
Yes No
If “Yes” please specify in details:

Agency/Organization/Individual Address Telephone number Purpose of contact
6.3. Intended duration of stay: 11 days 6.4. Intended date of entry (dd/mm/yyyy): 21/11/2024
6.5. Intended border gate of entry: Tan Son Nhat Int Airport (Ho Chi Minh City) 6.6. Intended border gate of exit: Noi Bai Int Airport
6.7. Residential address in Viet Nam: Equatorial Hotel 242 ��. Tr��n 6.8. Contact telephone number in Viet Nam:
B��nh Tr��ng, Ph��ng 4, Qu��n 5, Th��nh ph��
H�� Ch�� Minh 70000, Vietnam
Committed to declare temporary residence according to the provisions of

Vietnameses laws
6.9. Have you been to Viet Nam in the last 01 year?
Yes No
If “Yes” please specify

Duration of stay Trip's purpose
(from date : / / / to : / / / )
From (dd/mm/yyyy): to (dd/mm/yyyy):
6.10. Do you have relatives who currently reside in Viet Nam??
Yes No
If “Yes” please specify the relatives’ information (relatives include: grandparents, father, mother, husband, wife, children, brothers, sisters… of the
applicant)
Full name Date of birth Nationality Relationship Residential address in Viet Nam
Accompany child(ren) under 14 years old who are issued with the same passport request to be issued the same e-Visa (if any):
Note: Do not request e-Visa issuance for the child(ren) who are issued with the same passport if he/she has his/her own passport.
No. Full name Sex Date of birth Photo

(recent photo, size 4x6cm, jpg/jpeg format, file size ≤ 2MB, face looking straight, no hat,
no glasses, polite clothes, white background)
8. TRIP’S EXPENSES, INSURANCE
8.1. Intended expenses (in USD): USD

8.2. Who will cover the trip’s expenses of the applicant:
a) The applicant b) Other agency/organization/individual

If choosing this option, please specify: If choosing this option, please specify:
Cash -Name of the agency/organization/individual::
- Address:
Credit card
- Telephone number:
Traveller's cheques
- Payment method:
Cash
Credit card
Does the applicant have health insurance arranged for their stay in Viet Nam?
Yes No
Please specify:
9. INFORMATION OF VIETNAM AGENCY/ORGANIZATION REQUESTING E-VISA (IF ANY)
9.1. Name of agency/organization:
9.2. Address: <nil>

9.3. Telephone number. <nil> 9.4. Email address:
9.5 Legal representative:
Full name:
Date of birth:
Nationality:
Sex:
Telephone number:
ID Card number:
Date of issue (dd/mm/yyyy):
Place of issue :
Permanently Residential address:
Contact address:
9.6. Purpose of requesting for e-Visa issuance for foreigner:
Working with the agency/organization
Organizing tourist program
Others
If “Others”, please specify:
10. COMMTMENT
10.1. For foreigners applying for e-Visa

I hereby declare that the above statements are true, accurate and I am fully responsible before the Vietnamese laws for the
information provided to apply for an e-Visa of Viet Nam and I am aware that the application fee is not refunded if the application
for e-Visa of Viet Nam is denied.
10.2. For agency/organization requesting for e-Visa issuance for foreigner to enter Into Viet Nam
The agency/organization named in Section 9 hereby declare that the information given above regarding e-Visa application for
foreigner is true, accurate and we are fully responsible before Vietnamese laws for the information provided to apply for an e-Visa
of Viet Nam for foreigner.
PLACE, DATE OF REQUEST:
PLACE OF REQUEST DATE OF REQUEST (dd/mm/yyyy)

7/November/2024
Done at (country/territory): ……………

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Mẫu (Form) NA1a

Kèm theo Thông tư số 22/2023/TT-

VIET NAM E-VISA APPLICATION FORM

1-2. Sex: 1.3. Date of birth (dd/mm/yyyy): 25/06/1981

2. E-VISA REQUEST INFORMATION

2.1. To issue e-Visa for: 2.2. E-Visa duration: 21/11/2024

3.1. Passport type:

Diplomatic Officials Ordinary Others

If “Others”, please specify:

Do you hold any other valid passports?

If “Yes”, please specify:

4.1. Contact address: VPO, BATHADA KHURD, TEH-VALLABHNAGAR, UDAIPUR 313602.

4.5. Emergency contact:

5.1. Current occupation:

Official Others Retired

5.2. Occupation information :

d) Telephone number of Company/Agency/School:

6. INFORMATION ABOUT THE TRIP

6.1. Purpose of entry:

If “Others”, please specify: Tourism

If “Yes” please specify in details:

Committed to declare temporary residence according to the provisions of

6.9. Have you been to Viet Nam in the last 01 year?

If “Yes” please specify

No. Full name Sex Date of birth Photo

8. TRIP’S EXPENSES, INSURANCE

8.1. Intended expenses (in USD): USD

a) The applicant b) Other agency/organization/individual

9. INFORMATION OF VIETNAM AGENCY/ORGANIZATION REQUESTING E-VISA (IF ANY)

9.1. Name of agency/organization:

9.2. Address: <nil>

Organizing tourist program

If “Others”, please specify:

10.1. For foreigners applying for e-Visa

PLACE, DATE OF REQUEST:

PLACE OF REQUEST DATE OF REQUEST (dd/mm/yyyy)

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