(Please fill in block capital letters)Note : If any particulars furnished below are found to be incorrect or if any information is found to have been withheld, the visa, if granted, is liable to be cancelled at any time.

1. Full name : Mr/Ms/Mrs.__________________________________________________

2. Permanent address _____________________________________________________
______________________________________________________________________

3. Place of birth_____________________Date of birth___________________________

4. Nationality____________________________________________________________

5. Nature of Passport : Diplomatic/Official/Ordinary/UN Laissez Passer.

6. Passport number __________________________     Date of issue_______________
    Place of issue ____________________________      Date of expiry______________

7. Occupation/Profession _________________________________________________

8. Period for which visa is required : From_________________To__________________

9. Point of entry/exit into Bhutan : Entry Point ___________Exit Point _______________

10. Purpose of visiting Bhutan _____________________________________________

11. Is this your first visit to Bhutan ? * Yes/No. If not, give details of earlier visit _____
_____________________________________________________________________

Place ________________
Date ________________ Signature of appplicant
(* Please delete whichever is not applicable)

_____________________________________________________________________

For official use only :

Type of visa ______________________ (Attach passport size photograph)
Visa number ______________________
Date of issue______________________
Visa clearance number ______________

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