HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDDX57C7D17

A. Personal Particulars (As in Passport)

Appointment Date : 16-OCT-2017 At : 9.30 Hrs.

Surname (As in Passport) KUNDU
Given Name (As in Passport) ADURI
Previous/other Name if any
Sex FEMALE Marital Status MARRIED
Date of birth 06-DEC-1972 Religion HINDU
Application Id :BGDDX57C7D17

Place of Birth Town/City KHULNA Country of Birth BANGLADESH

Citizenship /National ID No 4792101003362 Educational Qualification MATRICULATION
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BP0074378 Date of issue ( dd/mm/yyyy ) 26-APR-2017
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 25-APR-2022
Any other Passport/Identity Certificate held (if yes ,please fill in the following) YES
Country of issue BANGLADESH Place of issue DHAKA
Passport/IC No AC4571144 Date of issue(dd/mm/yyyy) 07-MAY-2012
Web Registration Date : 08-OCT-2017

Nationality/status BANGLADESH

Khulna
C. Applicants Contact Details

47/1, MAZUMDERPARA, SHEB BARI ROAD Phone No 01715268275

Present
address BIT, DAULATPUR Mobile /Cell No 1715268275
KHULNA, BANGLADESH 9203 Email address

Permanent 47/1, MAZUMDERPARA, SHEB BARI ROAD

Address BIT, DAULATPUR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Fathers DHIRAJ KUNDU BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mothers SHAFALI KUNDU BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse NABA KUMAR KUNDU BANGLADESH BANGLADESH 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)

Type Of Visa Required TOURIST VISA No of Entries MULTIPLE

Period of Visa ( Month) 12 Month Expected Date of Journey 30-OCT-2017
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit BY AIR/ HARIDASPUR

ADURI KUNDU
 Required Detail of TOURIST VISA
Places to be Visited KOLKATA

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in ASHOK KUMAR KUNDU
India
PATHARGHATA, RAJARHAT, NORTH 24 PGS, WB

Application Id :BGDDX57C7D17
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VK2912272
Visa Issued Place DHAKA Date of Issue 26-JUN-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 of Spouse
Present Occupation HOUSE WIFE Designation/Rank HOUSE WIFE
Employer name/business ADURI KUNDU
Employer Address 47/1, MAZUMDERPARA, BIT, DAULATPUR, 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 State Phone No.
1 DR KAZI SHAMIM AKTER 111/2,RAJA S.C MULLICK ROAD, KOLKATA WEST BENGAL. 00919831090693,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e ASHOK KUMAR KUNDU NABA KUMAR KUNDU
Address PATHARGHATA, RAJARHAT 47/1, MAZUMDERPARA, BIT
NORTH 24 PGS, WB DAULATPUR, KHULNA
Phone
00919775644312 01711815814
Number

J. DECLARATION:

a. I do not hold any other passport(s) other than those detailed above.
b. I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them.
c. 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.
d. 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.

..
08-OCT-2017
Date :. Applicants signature (as in Passport)