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HIGH COMMISSION OF INDIA

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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDY39EBF16

A. Personal Particulars (As in Passport)


Surname (As in Passport)
KHA
Given Nam e (As in Passport) SHAHIDUR RAHMAN
Previous/other Name if any
Sex

Web Registration Date : 29-AUG-2016

Application Id :BGDDY39EBF16

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

MALE
05-FEB-1972
SATKHIRA
19728719031569422
NIL
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

MARRIED
ISLAM
BANGLADESH
POST GRADUATE

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

06-APR-2015
05-APR-2020

Any Other Previous/Past Nationality


B. Passport Details

BF0076019
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

GONALE
GONALI NALTA, TALA
SATKHIRA, BANGLADESH 9420

Phone No
Mobile /Cell No

01725337685
1725337685

Email address

Permanent GONALE
Address
GONALI NALTA, TALA
SATKHIRA
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

MD NOWSAR ALI SHAIKH

BANGLADESH

BANGLADESH

SATKHIRA
BANGLADESH

Mothers

ARFATUNACH

BANGLADESH

BANGLADESH

SATKHIRA
BANGLADESH

Spouse

ASMA PARVIN

BANGLADESH

BANGLADESH

SATKHIRA
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)

MEDICAL VISA
(Month) 12 Month
BY ROAD GHOJADANGA

Type Of Visa Required


Period of Visa
Port Of Arrival

SHAHIDUR RAHMAN KHA

No of Entries
Expected Date of Journey
Port of Exit

MULTIPLE
30-SEP-2016
BY ROAD GHOJADANGA

Required Detail of

MEDICAL VISA

Hospital Name
Address
Doctor Name
Phone/Fax
Details

PEERLESS HOSPITEX HOSPITAL AND RESEARCH CENTER LTD


360, PANCHASAYAR, KOLKATA-700094
DR KOUSTUBH CHAKRABORTY

03324620692
GANGREEN OF RT GREAT TOE

ISLAMI BANK CENTRAL HOSPITAL

KAKRAIL, DHAKA
DR MAHAMUDUL HUQUE

88029360334

Purpose of Visit : MEDICAL TREATEMENT OF SELF


F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in MD LIAKAT HOSSAIN
India

Application Id :BGDDY39EBF16

PATHARGHATA , RAJARHAT, NORTH 24 PGS, WB.

Cities in India Visited KOLKATA


Type of Visa TOURIST VISA
Visa Number
VK0625243
Visa Issued Place DHAKA
Date of Issue
15-FEB-2016
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
Present Occupation PRIVATE SERVICE
Designation/Rank
TEACHER
Employer name/business SUVASUNI COLLEGE
Employer Address SUVASUNI, TALA, SATKHIRA
Phone Number
01710409282

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
In
ASMA PARVIN
Nam e MD LIAKAT HOSSAIN
Address PATHARGHATA , RAJARHAT
GONALE, GONALI NALTA
NORTH 24 PGS, WB.

Phone
00919775644312
Number

State

Phone No.

BANGLADESH

TALA, SATKHIRA
01919337685

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.

29-AUG-2016
Date :.

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Applicants signature (as in Passport)