HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDDVF387919

A. Personal Particulars (As in Passport)

Surname (As in Passport) ISLAM
Given Nam e (As in Passport) AMIRUL
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 17-FEB-1979 Religion ISLAM
Application Id :BGDDVF387919

Place of Birth Town/City JHENAIDAH Country of Birth BANGLADESH

Citizenship /National ID No 2697408861478 Educational Qualification GRADUATE
Visible identification marks NILL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BR0699042 Date of issue ( dd/mm/yyyy ) 08-FEB-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 07-FEB-2023
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)
Web Registration Date : 04-SEP-2019

Nationality/status
C. Applicant’s Contact Details

512 SENPARA PARABATA Phone No

Present
address KAFRUL, MIRPUR Mobile /Cell No1711374226
DHAKA, BANGLADESH 1216 Email address AMIRUL.IUK@GMAIL.COM

Permanent ALIPUR, HABASHPUR

Address MAHESHPUR
JHENAIDAH

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
JHENAIDAH
Father’s ABDUL LATIF SARKER BANGLADESH BANGLADESH BANGLADESH
JHENAIDAH
Mother’s MRS GULAPJAN BANGLADESH BANGLADESH BANGLADESH
JHENAIDAH
Spouse MRS ROZINA AKTER 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-SEP-2019
Port Of Arrival BY ROAD DAWKI Port of Exit BY ROAD DAWKI

AMIRUL ISLAM
 Required Detail of TOURIST VISA
Places to be Visited KOLKATA

Purpose of Visit : FOR RECREATION,SIGHT SEEING, CASUAL VISIT TO MEET FRIENDS OR RELATIVES, ATTENDING A SHORT TERM YOG
F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in HOTEL PARADISE INT
India
26/2B RAFI AHMED KIDWARI ROAD,

Application Id :BGDDVF387919
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VK9764623
Visa Issued Place DHAKA Date of Issue 29-JUN-2018
Countries visited in last 10 years
THAILAND,INDIA,INDONESIA,SINGAPORE,MALAYSIA
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 PRIVATE SERVICE Designation/Rank FAVP
Employer name/business MERCANTILE BANK LIMITED
Employer Address 61 DILKUSHA
Phone Number
2134887433
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 HOTEL PARADISE INT 26/2B RAFI AHMED KIDWARI ROAD KOLKATA WEST BENGAL. 91332862209,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e HOTEL PARADISE INT SHAQIF HASAN SAJIB
Address 26/2B RAFI AHMED KIDWARI ROAD 37 DILKUSHA
DHAKA-1000
Phone
91332862209 01711575809
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.

..……………………………………
04-SEP-2019
Date :………………………. Applicant’s signature (as in Passport)