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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDV5BE4315

A. Personal Particulars (As in Passport)

Surname (As in Passport)
HALDER
Given Nam e (As in Passport) SAROJIT
Previous/other Name if any

Male
19-OCT-1959
JESSORE
4110473228733
NIL
BANGLADESH

Sex

Application Id :BGDDV5BE4315

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

Religion
Country of Birth
Educational Qualification

Married
HINDU
BANGLADESH
ILLITERATE

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

01-OCT-2013
30-SEP-2018

Any Other Previous/Past Nationality

B. Passport Details

AG1298260
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) YES
Country of issue

Web Registration Date : 07-FEB-2015

Marital Status

Passport/IC No
Nationality/status

BANGLADESH
Y0027719
BANGLADESH

Place of issue
Date of issue(dd/mm/yyyy)

JESSORE
23-NOV-2006

C. Applicants Contact Details

Present
address

KODLA,SREDHORPUR
ABHAYNAGAR
JESSORE, BANGLADESH 7460

Phone No
Mobile /Cell No

01721515564

Email address

Permanent KODLA,SREDHORPUR
Address
ABHAYNAGAR
JESSORE
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

KALI PADA HALDER

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Mothers

PUTUL HALDER

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Spouse

BHAROTI HALDER

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

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)

SAROJIT HALDER

No of Entries
Expected Date of Journey
Port of Exit

Multiple
25-APR-2015
BY AIR/ HARIDASPUR

Required Detail of

TOURIST VISA
AKIPUR,AKIPUR
GOPALNAGAR,NORTH 24 PGS

Purpose of Visit : TOURISM

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

YES

MR DULAL HALDER
AKIPUR,AKIPUR, GOPALNAGAR,JESSORE

Cities in India Visited NORTH 24 PGS

Type of Visa TOURIST VISA
Visa Issued Place DHAKA
Countries visited in last 10 years

Application Id :BGDDV5BE4315

Places to be Visited

VI9230042

Visa Number
Date of Issue

25-FEB-2014

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 FARMER
Designation/Rank
FARMER
Employer name/business FARMER
Employer Address KODLA,SREDHORPUR,ABHAYNAGAR,JESSORE
Phone Number
01721515564

Past occupation if any OTHERS

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 MR SULAL HALDER AKIPUR,AKIPUR,GOPALNAGAR NORTH 24 PARGANAS WEST BENGAL . 00918745963690,

2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
Nam e MR DULAL HALDER
BHAROTI HALDER
Address AKIPUR,AKIPUR
KODLA,SREDHORPUR
GOPALNAGAR,NORTH 24 PGS

Phone
00918745963690
Number

ABHAYNAGAR,JESSORE
01721515564

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.

07-FEB-2015
Date :.

..
Applicants signature (as in Passport)