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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDV8643216

Previous/other Name if any

Sex

Web Registration Date : 05-MAR-2016

Application Id :BGDDV8643216

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

Male
06-JAN-1970
KHULNA
19704793305012650
NIL
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

Married
ISLAM
BANGLADESH
HIGHER SECONDARY

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

17-MAY-2015
16-MAY-2020

Any Other Previous/Past Nationality

B. Passport Details

BF0687952
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. Applicants Contact Details
Present
address

PABLA BANIK PARA,DAULATPUR

DAULATPUR
KHULNA, BANGLADESH 9202

Phone No
Mobile /Cell No

01711584716

Email address

Permanent PABLA BANIK PARA,DAULATPUR

Address
DAULATPUR
KHULNA
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

SHAKH SAMIR UDDIN

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Mothers

MRS NOOR JAHAN BEGUM

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Spouse

MOUSUMI ISLAM

BANGLADESH

BANGLADESH

KHULNA
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

SK SHAHIDUL ISLAM

No of Entries
Expected Date of Journey
Port of Exit

Multiple
30-APR-2016
BY AIR/ HARIDASPUR

Appointment Date : 14-MAR-2016 At : 11.30

A. Personal Particulars (As in Passport)

Surname (As in Passport)
ISLAM
Given Nam e (As in Passport) SK SHAHIDUL

Required Detail of

TOURIST VISA
KAZIPARA,BARASAT
BARASAT,N 24 PGS.

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India

NO

Cities in India Visited

Type of Visa
Visa Issued Place
Countries visited in last 10 years

Application Id :BGDDV8643216

Places to be Visited

Visa Number
Date of Issue

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 PRIVATE SERVICE
Designation/Rank
Employer name/business SK SHAHIDUL ISLAM
Employer Address DAULATPUR,KHULNA
Phone Number
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

State

Phone No.

1 KAMAL SIKDER KAZIPARA,BARASAT NORTH 24 PARGANAS WEST BENGAL . 00919088666818,

2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
Nam e KAMAL SIKDER
SK RUHUL AMIN
Address KAZIPARA,BARASAT
DEANA,EAST PARA,DAULATPUR,
BARASAT,N 24 PGS.

Phone
00919088666818
Number

KHULNA
01715401161

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.

05-MAR-2016
Date :.

..
Applicants signature (as in Passport)

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