APPLICATION FORM

( Registration )

020914JW7S3L
Application ID No.

020914JW7S3L

Appointment Date

04/09/2014

FOR OFFICE USE ONLY

Reg. No.

Personal Details
Surname
DAS
Given Name
SOUVIK
Sex
Male
Date of Birth
04/10/1995
Height (in cm)
Age as on today
Year(s)
18
Month(s)
10
Day(s)
Place of Birth
SYLHET, BANGLADESH,SYLHET,BANGLADESH
Father's Name
JOYANTA DAS
Mother's Name
SUPTI CHOWDHURY
Spouse's Name
Religion
HINDU
Any Identification mark(s) preferably visible
BLACK MARK IN LEFT HIP
Present nationality
BANGLADESH
Manner of acquiring present nationality
Birth
Date of acquiring present nationality
04/10/1995
Whether holding dual
NO
nationality? If yes,
Name of the country of second nationality
provide the following:- Passport No. of second country
Date of Issue
Date of Expiry
Whether travelled on this passport earlier
to India

Whether person of Indian Origin

180
30

Paste your
Recent passport size
photograph here

Previous nationality

NO

Address of last residence (Outside India)

Address
City

HOUSE NO.-15/3, ROAD NO.-1, BLOCK-E, SHAHJALAL UPASHAHAR, SYLHET MAIN POST OFFICE,SYLHET SADAR,
SYLHET
SYLHET
Country
BANGLADESH

Address intended for longer stay in India (Registration)

Address
HALL-6, MAHATMA GANDHI AVENUE, A-ZONE, DURGAPUR, WEST BENGAL 713209
City/ District
BURDWAN
State
WEST BENGAL
Pin Code
713209
Phone Number
Mobile Number
9635068530

Any Other Address in India

Address
City/ District
Pin Code
Phone Number

State
Mobile Number

Email/Occupation/Profession Details
E-Mail Id
Profession/Occupation

STUDENT

Passport Details
Passport Number
Date of Issue

AD5683533
30/09/2012

Place of Issue
Expiry Date

BANGLADESH, DHAKA
29/09/2017

Place of Issue
Expiry Date
Visa Type

BANGLADESH, DHAKA
18/08/2016
STUDENT VISA

Visa Details
Visa Number
Date of Issue
Valid For

VJ2184124
19/08/2014
Multiple Entry

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020914JW7S3L
Application ID No.

020914JW7S3L

Special endorsement, if any

Appointment Date

04/09/2014

N.I.T. DURGAPUR

Organization/Company/Institute/Hospital Details
Name
NATIONAL INSTITUTE OF TECHNOLOGY DURGAPUR
Address
MAHATMA GANDHI AVENUE, A-ZONE, DURGAPUR, WEST BENGAL 713209
State
WEST BENGAL
City
BURDWAN
Telephone Number
03432752040
Email ID

Arrival Details
Place of embarkation/boarding for India
Date of arrival in India
Place of disembarkation/arrival in India
Mode of Journey
Air
Purpose of visit to India
Education

DHAKA AIRPORT,DHAKA,BANGLADESH
22/08/2014
KOLKATA AIRPORT
Flight/ Ship/ Bus/ Train No.

Previous Registration Details in India

Registration Number

Place of Registration

Visa Type

Duration From

To

Details of family members/attendant/dependents, if any accompanying.

Name

Nationality

Passport Number

Person to be contacted in Case of Emergency

Name
Address
City
Phone Number

Category

Relationship
Country

Others

Military service details

Organisation
Rank
Country of Last Posting

Designation
Place of Last Posting

Signature of the Applicant

Date_ _ _ _ _ _ _ _ _ _ _ _ _

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Relationship

020914JW7S3L
Application ID No.

020914JW7S3L

Appointment Date

04/09/2014

List of mandatory and non mandatory documents

Mandatory Documents.
1. Photo : Applicants Photo
2. Residence proof : Form C copy from Hotel or Lodge/ Electricity bill/ Landline/ Telephone /Municipal Bill of the landlord in case of staying in a house of relative or freind along with
a letter and photo-id card of the landlord.In case of rented accommodation copy of Lease and Licence agreement (1st and last page and page containing its validity).

3. Form S/ Bonafide certificate : Form S/ Bonafide certificate.

4. Passport and Visa : Photo page, page indicating validity, page bearing arrival stamp of Indian immigration,visa with endorsdement.

Non mandatory Documents.

1. NOC : If the student is coming for MBBS/BDS course on provisional student visa, then NOC from Ministry of Health & Family Welfare is mandatory.
2. Others : if document type is not in the list.

Registration office address

Office Name
Address

:
:

City/District
State
Pin Code
Phone Number

:
:
:
:

FRO ASANSOL DURGAPUR or BURDWAN

Bungalow No 5, 2nd Avenue, Evelyn Lodge, Kumarpur, Asansol - 713304 or DIB office, Court
Compound, Burdwan-713101
BURDWAN
WEST BENGAL
0
2251526

Office opening time:

11.00
Applications are accepted upto: 15.00

closing time:

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