Form for furnishing the details under section 420(3)

To

[Designation of Prescribed Authority]

Sir/Madam,

I give below the necessary particulars as required under section 420(3):

1.

Name

(Refer Note 1)

2.

Name of Father/Husband*

(Refer Note 1)

3.

Permanent Account Number

4.

Address

(Refer Note 2)

5.

Contact details

Mobile Number

Country Code

Number

Email ID

6.

Nature of Business /Profession in India

7.

Purpose of visit outside India

8.

Estimated period of stay outside India

9.

Passport Number/Emergency Certificate Number details

(i)

Passport/Emergency certificate number

(ii)

Date of Issue

dd/mm/yyyy

(iii)

Country where issued

(iv)

Place where issued

Verification

I, , do hereby declare that the information provided above is true and correct to the best of my knowledge. I

have not concealed any relevant fact.

*Delete whichever is not applicable

Date:

Place:

(Signature of Applicant)