HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDDV15EE418

A. Personal Particulars (As in Passport)

Appointment Date : 21-JAN-2018 At : 8.15 Hrs.

Surname (As in Passport) SARKAR
Given Name (As in Passport) ANANDA MOHAN
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 13-JUN-1963 Religion HINDU
Application Id :BGDDV15EE418

Place of Birth Town/City KHULNA Country of Birth BANGLADESH

Citizenship /National ID No 4715355587874 Educational Qualification BELOW MATRICULATION
Visible identification marks NILL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BR0210791 Date of issue ( dd/mm/yyyy ) 18-DEC-2017
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 17-DEC-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 : 13-JAN-2018

Nationality/status

Khulna
C. Applicant’s Contact Details

3 NO KOYRA Phone No 01749130391

Present
address MODINABAD, KOYRA Mobile /Cell No 1749130391
KHULNA, BANGLADESH 9290 Email address

Permanent 3 NO KOYRA
Address MODINABAD, KOYRA
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s KALI PADA SARKAR BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s ASALATA SARKAR BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse BIJALI RANI SARKAR 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 29-JAN-2018
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

ANANDA MOHAN SARKAR

 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 :BGDDV15EE418
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 LAND HOLDER Designation/Rank LAND HOLDER
Employer name/business ANANDA MOHAN SARKAR
Employer Address 3 NO KOYRA MODINABAD KOYRA 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 DK INTERNATIONAL HOTEL 11/1A MARQUSE STREET KOLKATA WEST BENGAL. 22556282,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e ASHOK KUMAR SARKAR BIJALI RANI SARKAR
Address PATHARGHATA, RAJARHAT 3 NO KOYRA, MODINABAD
NORTH 24 PGS, WB KOYRA, KHULNA
Phone
00919775644312 01749130391
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.

..……………………………………
13-JAN-2018
Date :………………………. Applicant’s signature (as in Passport)