BGDR28835015MD520101

Topics: West Bengal, India, Travel document Pages: 8 (614 words) Published: March 30, 2015
Asst High Commission of India Rajshahi
House No-284, Sector-2,Housing Estate
Uposhahar,Rajshahi

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www.ahcirajshahi.org
00880721861213

Visa Application Form

Signature

BGDR28835015

A. Personal Particulars (As in Passport)
Surname (As in Passport)
SHAHIDULLAH
Given Nam e (As in Passport) MD
Previous/other Name if any

Male
01-JAN-1952
CHAPAINAWABGANJ
19527026608152915
N/A
BANGLADESH

Sex

Web Registration Date : 13-MAR-2015

Application Id :BGDR28835015

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
HIGHER SECONDARY

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

10-FEB-2015
09-FEB-2020

Any Other Previous/Past Nationality
B. Passport Details

BE0493305
CHAPAINAWABGANJ

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. Applicant’s Contact Details
Present
address

BODUMIAPARA, RAJARAMPUR
CHAPAINAWABGANJ SADAR
CHAPAINAWABGANJ, BANGLADESH 6300

Phone No
Mobile /Cell No

01719933808

Email address

Permanent BODUMIAPARA, RAJARAMPUR
Address
CHAPAINAWABGANJ SADAR
CHAPAINAWABGANJ
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Father’s

ELIYES UDDIN BISWAS

BANGLADESH

CHAPAINAWABGANJ
BANGLADESH

Mother’s

SHOHOR BANU

BANGLADESH

CHAPAINAWABGANJ
BANGLADESH

Spouse

MST NASERA BANU

BANGLADESH

CHAPAINAWABGANJ
BANGLADESH

Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO E. Details of Visa Sought

TOURIST VISA
(Month) 12 Month
BY ROAD MAHADIPUR

Type Of Visa Required
Period of Visa
Port Of Arrival

(Visa shall be valid from the Date of Issue and not from the Date of Journey)

MD SHAHIDULLAH

No of Entries
Expected Date of Journey
Port of Exit

Multiple
28-MAR-2015
BY ROAD MAHADIPUR

Required Detail of

TOURIST VISA
SONKOR NETRALOY
KOLKATA

Purpose of Visit : TOURISM
F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India

NO

,

Cities in India Visited
Type of Visa
Visa Issued Place
Countries visited in last 10 years

Application Id :BGDR28835015

Places to be Visited

Visa Number
Date of Issue

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
N
Employer name/business OWNER
Employer Address 05, STADIUM MARKET, CHAPAINAWABGANJ
Phone Number
01719933808

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 POLASH KUMAR GHOSPARA, MONGALBARI MALDA WEST BENGAL . 8653680151, no 2 .,
3 .,
4 .,
I. Details of Two Reference
In India
Nam e POLASH KUMAR
ABDUL ZABBAR
Address GHOSPARA, MONGALBARI
CHAPAINAWABGANJ
OLD MALDA, MALDA

Phone
8653680151
Number

In

State

Phone No.

BANGLADESH

CHAPAINAWABGANJ
01719613696

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...
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