Day Month Year Day Month Year

Application No

1. Details Of Passport
i. Passport No / ii. Place of issue

Day Month Year Day Month Year

iii. Date of issue / iv. Date of expiry
2. Name in full as
Shown in passport
3. Nationality
4. Gender / i. Male / ii. Female

Day Month Year

5. Date of Birth
i. Place of Birth / ii. Country
6. Occupation
7. Civil status / i. Single / ii. Married / iii. Divorced / iv. Widowed
8. If Married Sri Lankan
i. Full Name of Spouse
ii. Passport Number / ii. Personal ID Number
9. Address in the
Country of Domicile
10. Address in Sri Lanka
11. Contact Details
i. Telephone Number / ii. Mobile
iii. Fax
iv. E-Mail

Day Month Year

12. Date of arrival

Day Month Year

13. Date of expiry of visa /
landing Endorsement
14. Extension of visa / Months

Required for

15. Exchange brought in
i. Type of currency / ii. Amount
iii. Amount cashed
v. Credit card available / Yes / No
16. Details of previous visit to Sri Lanka within immediate six months if any,
i. Date of arrivals / ii. Date of departure / iii. Duration
iv. Total
17. Whether you are in possession of a return ticket / Yes / No
18. Reasons for extension
i. Holiday / ii. Visit Relations / iii. Business
iv. Other , Specify
v. Documents annexed in support to the above reason
1
2
3
4

I hereby declare that to the best of my knowledge and belief the foregoing statements are true, that I shall not engage myself in any employment paid or unpaid , or in any business or trade on arrival or during my stay in Sri Lanka and that I shall leave Sri Lanka before the date of expiry of the period of my authorized stay. I also undertake to notify the Controller of Immigration & Emigration, Colombo, immediately any change of my address, while in Sri Lanka, occurs.

…………………………………………….……

Signature of applicant & Date

D/A / D/E / Cashed / RT
Remarks
Visa Fee (Rs) / Tax (Rs) / Penalty (Rs) / Amount (Rs)
Date / Processing Officer / For Controller General/Controller/Deputy Controller /Assistant Controller