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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDV01F2416

A. Personal Particulars (As in Passport)

Surname (As in Passport)

KAMRUSZZAMAN

Given Nam e (As in Passport)

Previous/other Name if any

Male
02-MAY-1978
JESSORE
4112325773798
N/A
BANGLADESH

Sex

Web Registration Date : 02-JAN-2016

Application Id :BGDDV01F2416

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 )

15-AUG-2011
14-AUG-2016

Any Other Previous/Past Nationality

B. Passport Details

AB2228852
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

UZZALPUR, DIGDANA
JHIKARGACHHA
JESSORE, BANGLADESH 7420

Phone No
Mobile /Cell No

01712642917

Email address

Permanent UZZALPUR, DIGDANA

Address
JHIKARGACHHA
JESSORE
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

FAZLUL HAQUE

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Mothers

RABAYA BEGUM

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Spouse

HAZIRA BEGUM

BANGLADESH

BANGLADESH

JESSORE
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 AIR/ HARIDASPUR

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)

KAMRUSZZAMAN

No of Entries
Expected Date of Journey
Port of Exit

Multiple
02-FEB-2016
BY AIR/ HARIDASPUR

Required Detail of

TOURIST VISA
WEST BENGAL

Purpose of Visit : TOURISM

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

YES

SAROK, MUROGACHA
KRISHNONAGAR, NADIA,

Cities in India Visited NADIA

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

VJ0458763

Visa Number
Date of Issue

14-MAY-2014

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
PROPITER
Employer name/business SADIA ENTERPRISE
Employer Address BANKRA BAZAR, JHIKARGACHHA, JESSORE
Phone Number
01712642917

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 ROYAL GARDEN 163 A, PARK STREET, KOLKATA, WEST BENGAL - 700 017 KOLKATA WEST BENGAL . +91-9836940037,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
Nam e KATTIK TARAFDER
BIKASH MODOK
Address SAROK, MUROGACHA
SONAKUR, SHONAKUR BAKRA
KRISHNONAGAR, NADIA

Phone
9732125717
Number

JHIKARGACHHA, JESSORE
01713903806

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.

02-JAN-2016
Date :.

..
Applicants signature (as in Passport)

Application Id :BGDDV01F2416

Places to be Visited