A ut ho r izat io n L et t er B パスポート記載のローマ字にて姓名を記入 A日付を記入 23/01/2015 Date: ________________ NIPPON HANAKO This is to certify that I,…………………………………………………………………………………………(Applicant’s name), authorize my agent/representative whose name, contact details and signature are verified below, to submit the India Visa application as well as collect the passport on my behalf. Details of Agent/ Representative: Milvento Corporation Name of the Agency (If Applicable): ...…………………………………………………………………….. Representative Name (who will submit the application/ collect the passport): ……………………..... NISHIKAWA Kiyoko KAWABATA Masuhiro ➀ ………………………………………………… ➁ ………………..……………………………………… TENDO Ayako TSUO Takeshi ➂ ………………..……………………………….. ➃ ………………..……………………………………... Identification Number of the Representative: …………………………………………………………….. ID NO. : JOC / MLV-0092 ID NO. : JOC / MLV-0091 ➀ ………………………………………………… ➁ ………………..……………………………………… ID NO. : 6288 0532 3110 ID NO. : JOC / MLV-0093 ➂ ………………..……………………………….. ➃ ………………..……………………………………... Contact Details: ……………………………………………………………………………………………… 記入方法の解説 …………………………………………………………………………………………………………………. A～Dの青文字の説明に沿いご記入ください …………………………………………………………………………………………………………………. 赤文字の記入例の部分にお客様の情報を …………………………………………………………………………………………………………………. 必ずご本人様の自署にてご記入ください インドビザセンター Signature of the authorized agent/ representative: ……………………………………………………… Please note that agent/ representative must bring this authorization letter in original along with their original identity proof document, for verification purpose. Neither the India Visa Application be accepted nor the passport be handed over without this original authorization letter and original identity proof. C パスポートの「所持人自署」と同じ署名を記入 日本 花子 Applicant’s Signature : ……………………………………………………………. NIPPON HANAKO Applicant’s Full Name: ……………………………………………………………. D パスポート記載のローマ字にて姓名を記入（②と同じ）
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