Embassy of India s1

Assistant High Commission of India Mombasa

Application for Miscellaneous Services

1. Name :

2. Father’s/Husband’s Name :

3. Date of Birth : Place of Birth :

4. Permanent Address in India, if any:

Tel No.

5. Present Address in Kenya:

Tel No.

6. New Address : (if application is for change of address)

7. Details of current passport: Passport No. : Date of Issue :

Place of Issue : Valid Until :

8. Service Required: Please tick and strike out the others:

a. Attestation of Affidavit b. Authentication/attestation of documents c. Power of Attorney d. Change of Address e. Police Clearance Certificate (for: please write name of country) f. PIO Endorsement

9. Please attache: copy of passport, all documents, in duplicate, copy of PIO or OCI card, if any, and one extra photograph

Date: ______T.I. or Signature of Applicant ------For official use: Receipt No. Amount Ksh: ______Date Given:______

Misc. Service No. ______Dt. ______Initial of Counter staff