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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDY4E39516

A. Personal Particulars (As in Passport)

Surname (As in Passport)
MORAL
Given Nam e (As in Passport) MOHAMMAD BABU
Previous/other Name if any
Sex

Application Id :BGDDY4E39516

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
MATRICULATION

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

04-SEP-2016
03-SEP-2021

Any Other Previous/Past Nationality

B. Passport Details

BL0799160
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 : 10-SEP-2016

MALE
12-MAR-1977
KHULNA
19774714057525505
NIL
BANGLADESH

Passport/IC No
Nationality/status

BANGLADESH
AA2913467
BANGLADESH

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

DHAKA
02-NOV-2011

C. Applicants Contact Details

Present
address

DEGOLEA, DIGHOLIA
DIGHALIA
KHULNA, BANGLADESH 9220

Phone No
Mobile /Cell No

01933852919
1933852919

Email address

Permanent DEGOLEA, DIGHOLIA

Address
DIGHALIA
KHULNA
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

JEHAD ALI MORAL

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Mothers

HAZARA BEGUM

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Spouse

NASEMA

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)

MEDICAL VISA
(Month) 12 Month
BY AIR/ HARIDASPUR

Type Of Visa Required

Period of Visa
Port Of Arrival

MOHAMMAD BABU MORAL

No of Entries
Expected Date of Journey
Port of Exit

MULTIPLE
07-OCT-2016
BY AIR/ HARIDASPUR

Required Detail of

MEDICAL VISA

Hospital Name
Address
Doctor Name
Phone/Fax
Details

RUBY GENERAL HOSPITAL LTD.

KASBA GOLPARK, EM BYPASS, KOLKATA-700107
INDRAJIT MANDAL

033-39871800
ISCHAEMIC HEART DISEASE

KHULNA MEDICAL COLLEGE HOSPITAL

SONADANGA, KHULNA
GOUTAM KUMAR MUKHERJEE

01718266689

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 :BGDDY4E39516

PATHARGHATA , RAJARHAT, NORTH 24 PGS, WB.

Cities in India Visited KOLKATA

Type of Visa MEDICAL VISA
Visa Number
VK0616401
Visa Issued Place DHAKA
Date of Issue
09-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 FARMER
Designation/Rank
FARMER
Employer name/business MOHAMMAD BABU MORAL
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
NASEMA
Nam e MD LIAKAT HOSSAIN
Address PATHARGHATA , RAJARHAT
DEGOLEA, DIGHOLIA
NORTH 24 PGS, WB.

Phone
00919775644312
Number

In

State

Phone No.

BANGLADESH

DIGHALIA, KHULNA
01933852919

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.

10-SEP-2016
Date :.

..
Applicants signature (as in Passport)