HIGH COMMISSION OF INDIA
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DHAKA(BANGLADESH)
Visa Application Form
Signature
BGDDY5283D16
Previous/other Name if any
Sex
Web Registration Date : 11-SEP-2016
Application Id :BGDDY5283D16
Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality
FEMALE
02-JAN-1977
KHULNA
4792101007581
NIL
BANGLADESH
Marital Status
Religion
Country of Birth
Educational Qualification
SINGLE
ISLAM
BANGLADESH
BELOW MATRICULATION
Nationality by Birth/ Naturalization
BY BIRTH
Date of issue ( dd/mm/yyyy )
28-JAN-2013
27-JAN-2018
Any Other Previous/Past Nationality
B. Passport Details
AE3672000
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
MOHESWARPASA, WEST SIDE OF DIGHI
BIT, DAULATPUR
KHULNA, BANGLADESH 9203
Phone No
Mobile /Cell No
01913211992
1910339956
Email address
Permanent MOHESWARPASA, WEST SIDE OF DIGHI
Address
BIT, DAULATPUR
KHULNA
D. Family Details
Relation
Name
Nationality
Prev. Nationality
Place/Country of Birth
Fathers
MUNSI MASI AHAMMAD
BANGLADESH
BANGLADESH
KHULNA
BANGLADESH
Mothers
SYEDA JINNATARA BEGUM
BANGLADESH
BANGLADESH
KHULNA
BANGLADESH
Spouse
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO
E. Details of Visa Sought
TOURIST VISA
(Month) 12 Month
BY AIR/ HARIDASPUR
Type Of Visa Required
Period of Visa
Port Of Arrival
(Visa shall be valid from the Date of Issue and not from the Date of Journey)
RABYA KHATUN
No of Entries
Expected Date of Journey
Port of Exit
MULTIPLE
30-OCT-2016
BY AIR/ HARIDASPUR
Appointment Date : 20-SEP-2016 At : 10.15
A. Personal Particulars (As in Passport)
Surname (As in Passport)
KHATUN
Given Nam e (As in Passport) RABYA
Required Detail of
TOURIST VISA
KOLKATA
Purpose of Visit : TOURISM
F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India
YES
MD LIAKAT HOSSAIN
PATHARGHATA , RAJARHAT, NORTH 24 PGS, WB.
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA
Visa Number
VI5947815
Visa Issued Place DHAKA
Date of Issue
20-MAR-2013
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 of Father
Present Occupation HOUSE WIFE
Designation/Rank
HOUSE WIFE
Employer name/business RABYA KHATUN
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
1 PATHARGHATA RAJARHAT NORTH 24 PARGANAS WEST BENGAL. 00919775644312,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
MUJIBUR RAHMAN
Nam e MD LIAKAT HOSSAIN
Address PATHARGHATA , RAJARHAT
MOHESWARPASA, BIT
NORTH 24 PGS, WB.
Phone
00919775644312
Number
In
State
Phone No.
BANGLADESH
DAULATPUR, KHULNA
01753109548
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.
11-SEP-2016
Date :.
..
Applicants signature (as in Passport)
Application Id :BGDDY5283D16
Places to be Visited
