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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDY54B4D16

Previous/other Name if any

FEMALE
31-JAN-1955
KHULNA
4792101007582
NIL
BANGLADESH

Sex

Web Registration Date : 12-SEP-2016

Application Id :BGDDY54B4D16

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

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 )

28-JAN-2013
27-JAN-2018

Any Other Previous/Past Nationality

B. Passport Details

AE8670384
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 9202

Phone No
Mobile /Cell No

01913211992
1994405944

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

SYED JAMSED ALI

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Mothers

TENGIDA BEGAM

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Spouse

MASI AHAMMAD

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

SYEDA JINNATARA BEGAM

No of Entries
Expected Date of Journey
Port of Exit

MULTIPLE
30-OCT-2016
BY AIR/ HARIDASPUR

Appointment Date : 21-SEP-2016 At : 10.45

A. Personal Particulars (As in Passport)

Surname (As in Passport)
BEGAM
Given Nam e (As in Passport) SYEDA JINNATARA

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
VI5947814
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 Spouse
Present Occupation HOUSE WIFE
Designation/Rank
HOUSE WIFE
Employer name/business SYEDA JINNATARA BEGAM
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
MASI AHAMMAD
Nam e MD LIAKAT HOSSAIN
Address PATHARGHATA , RAJARHAT
MOHESWARPASA, BIT
NORTH 24 PGS, WB.

Phone
00919775644312
Number

In

State

Phone No.

BANGLADESH

DAULATPUR, KHULNA
01922720395

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.

12-SEP-2016
Date :.

..
Applicants signature (as in Passport)

Application Id :BGDDY54B4D16

Places to be Visited