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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDW8D39A15

A. Personal Particulars (As in Passport)

Surname (As in Passport)
HOSSAIN
Given Nam e (As in Passport) AFZAL
Previous/other Name if any

Male
01-JAN-1941
JESSORE
4124705056428
NA
BANGLADESH

Web Registration Date : 11-MAY-2015

Application Id :BGDDW8D39A15

Sex
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
HIGHER SECONDARY

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

29-OCT-2012
28-OCT-2017

Any Other Previous/Past Nationality

B. Passport Details

AD4885585
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

HOUSE NO:52, BURHANSHA SAROK

KARBALA, JESSORE MAIN POST OFFICE
KOTWALI, JESSORE, BANGLADESH 7400

Phone No

01711143485
Email address mazad_71@yahoo.com

Mobile /Cell No

Permanent HOUSE NO:52, BURHANSHA SAROK

Address
KARBALA, JESSORE MAIN POST OFFICE
KOTWALI, JESSORE
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

YOUSUF HOSSAIN

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Mothers

MST SUNDORI BIBI

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Spouse

MORZINA

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

E. Details of Visa Sought

MEDICAL 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)

AFZAL HOSSAIN

No of Entries
Expected Date of Journey
Port of Exit

Multiple
15-MAY-2015
BY AIR/ HARIDASPUR

Required Detail of

MEDICAL VISA

Hospital Name
Address
Doctor Name
Phone/Fax
Details

APOLLO GLENEAGLES HOSPITAL

58 CANAL CIRCULAR ROAD, KOLKATA-700 054
MAHESH K GOENKA

LABAID SPECIALIZED HOSPITAL

HOUSE:6, ROAD:4, DHANMONDI, DHAKA

MAMUN AL MAHTAB

Purpose of Visit : MEDICAL TREATEMENT OF SELF

F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India

Application Id :BGDDW8D39A15

Cities in India Visited

Type of Visa
Visa Number
Visa Issued Place
Date of Issue
Countries visited in last 10 years
NA
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
OWNER
Employer name/business AFZAL MOTOR WORKS
Employer Address PETERSON ROAD, PURATAN KASBA, JESSORE
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 SILVER SPRING BLOCK:1, FLAT:6A, BYPASS KOLKATA WEST BENGAL . 9830043166, atdas@venl.co.in
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
Nam e AMIT KUMAR DAS
REHANA PARVEEN
Address 363 DASKHINDARI, LAHA BAGAN
HOUSE:18, ROAD:3/B, SECTOR:09
KOLKATA-700 048

Phone
9830043166
Number

UTTARA, DHAKA
01713092903

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.

11-MAY-2015
Date :.

..
Applicants signature (as in Passport)