Registration Form for Indian nationals and Persons of Indian Origin

HIGH COMMISSION OF INDIA No. 15, Rio Negro Close, Maitama, Abuja. Tel:+(234)-09-4132323/4132726 & Fax: 4132324 Email: regn.abuja@hcilagos.org Website: www.hicomindlagos.com BRANCH OFFICE - LAGOS: 8 A, Walter Carrington Crescent ,Victoria Island Tel:01-2627680/2615905 Fax:2612660 Email:regn.lagos@hcilagos.org Registration Form for Indian nationals and Persons of Indian Origin
Users are requested to fill the below form. Your Registration details would be sent to the Office for verification. If approved, you will be sent a confirmation with your Registration Code. Please note that ALL FIELDS ARE MANDATORY to be filled unless or otherwise specified.
Username (Email Address)
01. Name
02. Surname
Sex	Male Female
04. Qualifications
05. Date of Birth (DD/MM/YYYY)
06. Place of Birth
07. Country of Birth	AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic RepublicCook IslandsCosta RicaCote d'IvoireCroatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's RepublicKorea, RepublicKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav RepublicMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated StatesMoldova, RepublicMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LUCIASaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United RepublicThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabweIndia
08. Father's Name
Marital Status	Married Single Married Divorced Others
10. Mother Tongue
11. Citizen of	AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic RepublicCook IslandsCosta RicaCote d'IvoireCroatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's RepublicKorea, RepublicKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav RepublicMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated StatesMoldova, RepublicMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LUCIASaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United RepublicThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabweIndia
Blood Group	A+ A+A--B+B--AB+AB--O+O--
13. Passport No
14. Date of Issue (DD/MM/YYYY)
15. Place of Issue
16. Passport Expiry Date (DD/MM/YYYY)
17. Residing In	BeninCameroonChadEquatorial GuineaNigeriaSao Tome and PrincipeNigeria
18. State in Nigeria	AbiaAbujaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNassarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfara
19. Date of First Arrival in Nigeria (DD/MM/YYYY)
20. Expected Final Year of Departure (if applicable)	N/A20062007200820092010201120122013201420152016N/A
21. Profession
22. Name and Address of Company/ Organisation in Nigeria
23. Designation
24. Postal Address in Nigeria
25. Residential Address in Nigeria
26. City in Nigeria
27. Office Tel in Nigeria
28. Res Tel in Nigeria
29. Mobile No in Nigeria
30. Fax No in Nigeria
31. PIO Card No (if any)
32. Cerpac No (if any)
33. Permanent Address in India
34. State of Origin in India	DelhiAndaman and Nicobar IslandsAndhra PradeshArunachal PradeshAssamBiharChhattisgarhChandigarhDadra and Nagar HaveliDaman and DiuDelhiGoaGujaratHaryanaHimachal PradeshJammu and KashmirJharkhandKarnatakaKeralaLakshadweepMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOrissaPondicherryPunjabRajasthanSikkimTamil NaduTripuraUttaranchalUttar PradeshWest Bengal
35. Details of person in India to be contacted in case of Emergency
36. Phone Nos of person to be contacted in case of Emergency
Details of Other Family Members residing with you
Relation Name Nationality Birthdate DD/MM/YYYY Blood Group Passport No Passport Expiry DD/MM/YYYY Work Details Contact Tel No Cerpac A+ A+A--B+B--AB+AB--O+O-- A+ A+A--B+B--AB+AB--O+O-- A+ A+A--B+B--AB+AB--O+O-- A+ A+A--B+B--AB+AB--O+O-- A+ A+A--B+B--AB+AB--O+O--
Notes from High Commission		_