HIGH COMMISSION OF INDIA
DHAKA(BANGLADESH) Paste your unsigned
recent color photograph.
Size: 2” X 2”
Visa Application Form
Signature
BGDDW6A3D019
A. Personal Particulars (As in Passport)
Surname (As in Passport) HAQUE
Given Nam e (As in Passport) MD MAHAMUDUL
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 03-JAN-1952 Religion ISLAM
Application Id :BGDDW6A3D019
Place of Birth Town/City BAGERHAT Country of Birth BANGLADESH
Citizenship /National ID No 2372748109 Educational Qualification GRADUATE
Visible identification marks LEG
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BP0018977 Date of issue ( dd/mm/yyyy ) 19-APR-2017
Place of issue AGARGAON Date of expiry (dd/mm/yyyy) 18-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 : 29-DEC-2019
Nationality/status
C. Applicant’s Contact Details
21/1, SUKRABAD, MOHAMMADPUR Phone No 01916663881
Present
address DHAKA Mobile /Cell No 1916663881
DHAKA, BANGLADESH 1207 Email address SHEHRIN.MAHMUD174053@GMAIL.COM
Permanent CHINGRAKHALI
Address MORRELGANJ
BAGERHAT
D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
BAGERHAT
Father’s S RAIHAN UDDIN AHMED BANGLADESH BANGLADESH BANGLADESH
BAGERHAT
Mother’s SHAFIA BEGUM BANGLADESH BANGLADESH BANGLADESH
DHAKA
Spouse FERDOUSI BEGUM 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 MEDICAL VISA No of Entries MULTIPLE
Period of Visa ( Month) 12 Month Expected Date of Journey 15-JAN-2020
Port Of Arrival BY AIR Port of Exit BY AIR
MD MAHAMUDUL HAQUE
Required Detail of MEDICAL VISA
Hospital Name SAKRA WORLD HOSPITAL DR REFATULLAH MEDI CARE CENTER
Address 52/3,DEVARABEESANAHALLI MARATHAHALLI, BENGALURU, HAPPY ARCADE 3RD FLOOR
Doctor Name DR SHANTHALA THUPPANNA DR M RAZIBUL ISLAM RAZON
Phone/Fax 91 9448019811 01511226666
Details URINARY TRACT INFECTION
Purpose of Visit : FOR FOREIGN NATIONALS COMING AS MEDICAL ATTENDANTS
F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India
,
Application Id :BGDDW6A3D019
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years
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 RETIRED Designation/Rank ACCOUNTANT OFFICER
Employer name/business FINANCIAL MANAGEMENT ACADEMY FIMA
Employer Address MIPUR 14
Phone Number
02 871 5399
Past occupation if any GOVERNMENT SERVICE
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 SHIVA PRAKRUTHI APARTMENT TALAAUVERY LAYOUT JAKKURU BENGALURU BANGALORE KARNATAKA. 91 9743709178, gaurav.j@gmail.com
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e GAURAV JAKKENAHALLI FERDOUSI BEGUM
Address 302 SHIVA PRAKRUTHI APARTMENT 21/1, SUKRABAD, MOHAMMADPUR
TALACAUVERY LAYOUT JAKKURU BENGALUR
Phone
91 9743709178 01915468205
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.
..……………………………………
29-DEC-2019
Date :………………………. Applicant’s signature (as in Passport)
