APPLICATION FORM

( Registration Extension )

12041914X1KP

Application ID No. 12041914X1KP Final Submission Date Fri Apr 12 11:14:12 IST 2019

FOR OFFICE USE ONLY

Reg. No. S 2 5 8 B G D 2 0 1 9

Personal Details
Surname SHARMA
Given Name ANIMESH Paste your
Sex Male Date of Birth 21/11/1988 Height (in cm) 167 Recent passport size
Age as on today Year(s) 30 Month(s) 7 Day(s) 24 photograph here
Place of Birth DINAJPUR,DINAJPUR,BANGLADESH
Father's Name SHURENDRO NATH SHARMA
Mother's Name PRAM BALA ROY
Spouse's Name SIMA RANI SHARMA
Religion HINDU Any Identification mark(s) preferably LEFT LEG EXTRA FINGER
visible

Present nationality BANGLADESH Previous nationality BANGLADESH

Manner of acquiring present nationality Birth
Date of acquiring present nationality
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 NO

Address of last residence (Outside India)

Address JOT SAT NALA, TARAK SHAHAR HAT, CHIRIRBANDAR
City DINAJPUR Country BANGLADESH

Address intended for longer stay in India (Registration)

Address GODAVARI BHABAN, RAMKRISHNA PALLY, PALBARI, MEDINIPUR
City/ District West Medinipur State WEST BENGAL
Pin Code 721101
Phone Number Mobile Number 9073337605
Any Other Address in India
Address
City/ District State
Pin Code
Phone Number Mobile Number
Email/Occupation/Profession Details
E-Mail Id sp40217@gmail.com
Profession/Occupation BUSINESS

Passport Details
Passport Number BQ0324372 Place of Issue BANGLADESH, DINAJPUR
Date of Issue 20/09/2017 Expiry Date 19/09/2022

Visa Details
Visa Number VK4253367 Place of Issue BANGLADESH, DHAKA
Date of Issue 31/10/2016 Expiry Date 30/10/2021
Valid For Multiple Entry Visa Type BUSINESS VISA
Special endorsement, if any

Organization/Company/Institute/Hospital Details
Name MYMENSINGH AGRO LIMITED UNIT
Address PRAN RFL CENTRE, 105 MIDDLE BADDA, DHAKA 1212, GPO BOX 83, BANGLADESHNLADESH

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 12041914X1KP
Application ID No. 12041914X1KP

State WEST BENGAL City West Medinipur

Telephone Number Email ID
Employer EPFO ID Establishment ID
Arrival Details
Place of embarkation/boarding for India HARIDASPUR,KOLKATA,INDIA
Date of arrival in India 14/02/2019
Place of disembarkation/arrival in India HARIDASPUR
Mode of Journey Road Flight/ Ship/ Bus/ Train No.
Purpose of visit to India Business

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 Relationship
Person to be contacted in Case of Emergency
Name DILIP KUMAR SHILL Relationship BROTHER
Address JOT SAT NALA, TARAKSHAHAR HAT, CHIRIRBANDAR City DINAJPUR
Country BANGLADESH Phone Number 8801710623935
Category Others

Military service details

Organisation Designation
Rank Place of Last Posting
Country of Last Posting

Current Registration Details

Are you registered in current locality FRRO/FRO in the current visit? YES Current 2610188JRDN3
Registration No.

Registration Extension Details

Current Registration Valid Upto 10/04/2019 Required for period of Year(s) 0 Month(s) 12 Day(s) 0
Reason Of Extension BUSINESS PURPOSE

Signature of the Applicant

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

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 12041914X1KP
Application ID No. 12041914X1KP

List of mandatory and non mandatory documents

Mandatory Documents.
1. Residence proof : Updated Form ‘C’ generated by Hotel or Lodge or Registered/Notarized Lease Deed, Utility Bill, Copy of photo-ID of the landlord along with declaration and Tenant
Police Verification

2. Photo : Applicant's Photo

3. Company related documents : Balance Sheet and Profit and Loss Account for the last or current financial year
4. Visa : Indian Visa
5. Passport : Bio- Data page of Passport along with page bearing last Indian Immigration arrival stamp
6. Company's Incorporation Certificate : Incorporation Certificate, Pages bearing details of shareholders, Director’s Identification No., Share holding Certificate showing percentage
of share held by the applicant

7. Income Tax paper : Income Tax Return (ITR) for the last assessment year for the applicant and the company, Form 16 (Part-A & Part-B) for the last assessment year and Form 26 AS for
the current assessment year

8. Registration Certificate : FRRO/FRO Registration Certificate/Residential Permit of the Business (B-2) Visa holder
9. RBI/ GOI Approval : Permission/approval from RBI/GOI in case of Joint Venture/Collaboration
10. Request letter : Request letter addressed to FRRO/FRO for visa related service
11. Undertaking letter : Undertaking Letter duly signed by an Indian Host or an Indian authorized signatory with name, phone no., designation and copy of a photo-ID ensuring repatriation,
if anything adverse comes to notice

Registration office address

Office Name : FRO WEST MEDINIPUR

Address : Paschim medinipur Police Line
City/District : West Medinipur
State : WEST BENGAL
Pin Code : 0
Phone Number : 263525

Office opening time: 10.00 closing time: 17.00

There is no need to submit hard copy to concerned

FRRO/FRO

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