HIGH COMMISSION OF INDIA

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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDYE098116

Previous/other Name if any

Sex

Web Registration Date : 22-OCT-2016

Application Id :BGDDYE098116

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

FEMALE
15-JAN-1997
JHALAKHATI
20074214331100474
NIL
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

SINGLE
HINDU
BANGLADESH
HIGHER SECONDARY

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

20-JAN-2016
19-JAN-2021

Any Other Previous/Past Nationality

B. Passport Details

BJO979130
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

WEST AURA
KATHALIA
JALAKATI, BANGLADESH 8400

Phone No
Mobile /Cell No

1612173889

Email address

Permanent POSHCHIM CHHITKI,

Address
POSHCHIM CHHITKI, KATHALIA
JHALAKATI
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

SUSHIL RANJAN HOWLADER

BANGLADESH

BANGLADESH

JHALAKATI
BANGLADESH

Mothers

KAZAL RANI HOWLADER

BANGLADESH

BANGLADESH

JHALAKATI
BANGLADESH

Spouse
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 GEDE

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)

RIA HOWLADER

No of Entries
Expected Date of Journey
Port of Exit

MULTIPLE
15-NOV-2016
BY ROAD GEDE

Appointment Date : 02-NOV-2016 At : 10.15 Hrs.

A. Personal Particulars (As in Passport)

Surname (As in Passport)
HOWLADER
Given Nam e (As in Passport) RIA

Required Detail of

TOURIST VISA
KOLKATA,
W.B. INDIA

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India

YES

31, JAGANNATH TAORI ROAD,

DAMDAM, KOLKATA, INDIA

Cities in India Visited INDIA

Type of Visa TOURIST VISA
Visa Issued Place DHAKA
Countries visited in last 10 years

VK0628658

Visa Number
Date of Issue

17-FEB-2016

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 of Father
Present Occupation STUDENT
Designation/Rank
ASSISTANT TEACHER
Employer name/business KBK HIGH SCHOOL
Employer Address BINAPANI BAZAR, KATHALIA
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 HOTEL SOMRAT 23, MARQUIS STREET KOLKATA WEST BENGAL. +913322520190,

2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In
SUSHIL RANJAN HOWLADER
Nam e ARUN HALDER
Address BOGULA HASKHALI,
KATHALIA
W.B.,INDIA

Phone
+951432704
Number

State

Phone No.

BANGLADESH

JHALAKHATI
01724229945

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.

22-OCT-2016
Date :.

..
Applicants signature (as in Passport)

Application Id :BGDDYE098116

Places to be Visited