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HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned


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Visa Application Form

Signature
BGDDWA8A4F17

A. Personal Particulars (As in Passport)


Surname (As in Passport) ISLAM
Given Nam e (As in Passport) MOHAMMAD NURUL
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 09-DEC-1965 Religion ISLAM
Application Id :BGDDWA8A4F17

Place of Birth Town/City JHENAIDAH Country of Birth BANGLADESH


Citizenship /National ID No 4411989175805 Educational Qualification MATRICULATION
Visible identification marks NONE
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BP0090913 Date of issue ( dd/mm/yyyy ) 27-APR-2017
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 26-APR-2022
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 : 20-MAY-2017

Nationality/status
C. Applicants Contact Details

MAGURAPARA, DAKBANGLA BAZAR, Phone No


Present
address SHADUHATI, JHENAIDAH SADAR Mobile /Cell No 1716489762
JHENAIDAH, BANGLADESH 7200 Email address ISLAMASHRAFUL1787@GMAIL.COM

Permanent MAGURAPARA, DAKBANGLA BAZAR,


Address SHADUHATI, JHENAIDAH SADAR
JHENAIDAH

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
JHENAIDAH
Fathers RUSTOM MONDOL BANGLADESH BANGLADESH BANGLADESH
JHENAIDAH
Mothers NURJAHAN BANGLADESH BANGLADESH BANGLADESH
JHENAIDAH
Spouse SAMSUN NAHAR 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 ( Months) 12 Months Expected Date of Journey 04-JUL-2017
Port Of Arrival BY ROAD GEDE Port of Exit BY ROAD GEDE

MOHAMMAD NURUL ISLAM


Required Detail of TOURIST VISA
Places to be Visited KOLKATA

Purpose of Visit : TOURISM


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

Application Id :BGDDWA8A4F17
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years

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 LINEMAN
Employer name/business POWER GREED COMPANY BANGLADESH LIMITED
Employer Address HAMDAH, JHENAIDAH SADAR
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 HOTEL ROYAL GARDEN 163 A, PARK STREET KOLKATA WEST BENGAL. +91 98369 40037,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e HOTEL ROYAL GARDEN ASHRAFUL ISLAM RASEL
Address 163 A, PARK STREET MAGURAPARA, DAKBANGLBAZAR
KOLKATA, WEST BENGAL 700017, INDIA SHADUHATI, JHENAIDAH SADAR
Phone
+91 98369 40037 01811001787
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.

..
20-MAY-2017
Date :. Applicants signature (as in Passport)

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