HIGH COMMISSION OF INDIA

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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDY549CC16

Previous/other Name if any

Application Id :BGDDY549CC16

Sex
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
HINDU
BANGLADESH
MATRICULATION

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

03-DEC-2012
02-DEC-2017

Any Other Previous/Past Nationality

B. Passport Details

AE8169518
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 : 12-SEP-2016

MALE
28-DEC-1978
KHULNA
4714057525794
NIL
BANGLADESH

Passport/IC No
Nationality/status

BANGLADESH
B0086655
BANGLADESH

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

KHULNA
09-OCT-2007

C. Applicants Contact Details

Present
address

DIGHOLIA, DIGHOLIA
DIGHALIA
KHULNA, BANGLADESH 9220

Phone No
Mobile /Cell No

01712149266
1992477764

Email address

Permanent DIGHOLIA, DIGHOLIA

Address
DIGHALIA
KHULNA
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

SHIBPADA GHOSH

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Mothers

KURANA BALA GHOSH

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Spouse

LIPIKA RANI GHOSH

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

PROSHANTA KUMAR GHOSH

No of Entries
Expected Date of Journey
Port of Exit

MULTIPLE
30-OCT-2016
BY AIR/ HARIDASPUR

Appointment Date : 20-SEP-2016 At : 9.30

A. Personal Particulars (As in Passport)

Surname (As in Passport)
GHOSH
Given Nam e (As in Passport) PROSHANTA KUMAR

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

ASHOK KUMAR GHOSH

PATHARGHATA , RAJARHAT, NORTH 24 PGS, WB.

Cities in India Visited KOLKATA

Type of Visa TOURIST VISA
Visa Number
VJ9349101
Visa Issued Place DHAKA
Date of Issue
22-NOV-2015
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 BUSINESS PERSON
Designation/Rank
PROPRIETOR
Employer name/business PROSHANTA KUMAR GHOSH
Employer Address DIGHALIA, 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
LIPIKA RANI GHOSH
Nam e ASHOK KUMAR GHOSH
Address PATHARGHATA , RAJARHAT
DIGHOLIA, DIGHOLIA
NORTH 24 PGS, WB.

Phone
00919775644312
Number

In

State

Phone No.

BANGLADESH

DIGHALIA, KHULNA
01712149266

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 :BGDDY549CC16

Places to be Visited