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BGDDXE01C815MS670605 .pdf


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HIGH COMMISSION OF INDIA
Paste your unsigned
recent color photograph.
Size: 2” X 2”

DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDXE01C815

Previous/other Name if any
Sex

Web Registration Date : 06-SEP-2015

Application Id :BGDDXE01C815

Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality

Female
05-JUN-1967
JESSORE
4129002693738
NIL
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

Married
ISLAM
BANGLADESH
BELOW MATRICULATION

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

02-OCT-2012
01-OCT-2017

Any Other Previous/Past Nationality
B. Passport Details

AD9698951
DHAKA

Passport No.
Place of issue

Date of expiry (dd/mm/yyyy)

Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of issue

Place of issue

Passport/IC No

Date of issue(dd/mm/yyyy)

Nationality/status
C. Applicant’s Contact Details
Present
address

DURGAPUR, BENAPOLE, BENAPOLE
BENAPOLE PORT
JESSORE, BANGLADESH 7431

Phone No
Mobile /Cell No

01711236930

Email address

Permanent DURGAPUR, BENAPOLE, BENAPOLE
Address
BENAPOLE PORT
JESSORE
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Father’s

KASHEM ALI

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Mother’s

MST BAHARUN NESA

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Spouse

MOHAMMAD ABDUR RAZZAQ

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO
E. Details of Visa Sought

(Visa shall be valid from the Date of Issue and not from the Date of Journey)

TOURIST VISA
(Month) 12 Month
BY AIR/ HARIDASPUR

Type Of Visa Required
Period of Visa
Port Of Arrival

MST AYSHA KHATUN

No of Entries
Expected Date of Journey
Port of Exit

Multiple
25-SEP-2019
BY AIR/ HARIDASPUR

Appointment Date : 16-SEP-2015 At : 10.00

A. Personal Particulars (As in Passport)
Surname (As in Passport)
KHATUN
Given Nam e (As in Passport) MST AYSHA

Required Detail of

TOURIST VISA
KOLKATA
W. B., INDIA

Purpose of Visit : TOURISM
F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India

YES

KOLKATA
W. B., INDIA,

Cities in India Visited KOLKATA
Type of Visa TOURIST VISA
Visa Number
VJ1557766
Visa Issued Place DHAKA
Date of Issue
03-JUL-2014
Countries visited in last 10 years
INDIA
Have you been refused an Indian Visa or extension of the same previously or deported from India ?
If yes above mention when and by whom with control
No/Date
G. Profession/Occupation Details
Present Occupation DEPENDENT
Designation/Rank
PROPRIETOR
Employer name/business M/S. ARNOB ENTERPRISE
Employer Address BENAPOLE PORT, JESSORE
Phone Number
01977993535

Past occupation if any
Are/have you worked with Armed forces/ Police/ Para Military forces ? NO
Organization
Designation
Place of Posting
Rank
H. Address of Place of Stay / Hotel
Place/Hotel Name
Address of Place / Hotel

1 HOTEL GOLDEN APPLE 9, SUDDER STREET KOLKATA WEST BENGAL . 0091-3366077500,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In
Nam e HOTEL GOLDEN APPLE
ALHAZ MD SHAMSUR RAHMAN
Address 9, SUDDER STREET
M/S. SHAMSUR RAHMAN
KOLKATA-700016, W. B., INDIA

Phone
0091-3366077500
Number

State

Phone No.

BANGLADESH

BENAPOLE, JESSORE
01711836375

J. DECLARATION:
a.
b.
c.
d.

I do not hold any other passport(s) other than those detailed above.
I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them.
I declare that the information given in the form is complete and correct and the visit to India will be undertaken for the
purpose indicated in the application.
I understand that in case the information provided in the form is found to be incorrect, I will be liable for denial of visit/ entry
or deportation and/ or other penalties during the visit as provided by Indian law.

06-SEP-2015
Date :……………………….

..……………………………………
Applicant’s signature (as in Passport)

Application Id :BGDDXE01C815

Places to be Visited


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