HIGH COMMISSION OF INDIA
DHAKA(BANGLADESH) Paste your unsigned
BOTH PHOTO'S SHOULD recent color photograph.
BE SAME Size: 2” X 2”
Visa Application Form
SURNAME SHOULD BE
SAME AS IN PASSPORT
NAME SHOULD BE Signature
BGDDV1895616 SAME AS IN PASSPORT
A. Personal Particulars (As in Passport)
Surname (As in Passport) HOSSAIN MUST BE SAME AS IN SIGNATURE AS SAME
Given Nam e (As in Passport) MAHMUD
PASSPORT AS IN PASSPORT
Previous/other Name if any
Sex Male Marital Status Married
Date of birth 01-JAN-1975 Religion ISLAM
Place of Birth Town/City DHAKA Country of Birth BANGLADESH
Citizenship /National ID No 197512345678111 Educational Qualification GRADUATE AS IN
Visible identification marks NA PASSPORT
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
GIVE YOUR CURRENT VALID
B. Passport Details PASSPORT NO
Passport No. XX123458 Date of issue ( dd/mm/yyyy ) 03-JAN-2016
Place of issue Date of expiry (dd/mm/yyyy) 02-JAN-2020
DHAKA
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. Applicant’s Contact Details
MUST BE SAME
A-1,B-2 Phone No
AS IN UTILITY
Present Mobile /Cell No 017111111111
address BB----- BILL ADDRESS
DHAKA, BANGLADESH 1200 Email address yyy@mail.com
Permanent A-1,B-2
Address BB----- GIVE YOUR
DHAKA VALID PHONE
NUMBER & EMAIL
D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
DHAKA
Father’s MD XYZ BANGLADESH BANGLADESH BANGLADESH
DHAKA
Mother’s MRS XYZ BANGLADESH BANGLADESH BANGLADESH
DHAKA
SHOULD NOT
Spouse XYZ BANGLADESH BANGLADESH BANGLADESH BE LEFT BLANK
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)
TOURIST VISA PORT
PORTSHOULD
SHOULDBE
BE Multiple
Type Of Visa Required No of Entries SPECIFIED
SAME
Period of Visa (Month) 126Month
MONTH Expected Date of Journey 25-JAN-2016
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit
BY AIR/ HARIDASPUR
TOURIST VISA
Required Detail of K
Places to be Visited
SHOULD NOT BE
LEFT BLANK GIVE YOUR PREVIOUS
Purpose of Visit : TOURISM
VISA NUMBER &
Application Id :BGDDV1895616
F. Previous Visit Details
Have You Ever visited India ? YES ISSUE DATE.
Address where You stayed in AA
India
BB, CC
Cities in India Visited A
Type of Visa TOURIST VISA Visa Number VN12345156
Visa Issued Place DHAKA Date of Issue 01-JAN-2015
Countries visited in last 10 years
THAILAND,UK,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 PRIVATE SERVICE Designation/Rank A
Employer name/business XYZ
Employer Address A B C 123
Phone Number 017111111111111
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 XYZ 9 MA ABC XYZ KOLKATA WEST BENGAL . 0091100000000,
2 ., PLEASE GIVE
3 ., GENUINE CONTACT
4 ., DETAILS
I. Details of Two Reference
In India In BANGLADESH
MD XYZ MD ABC
Name
6
Address ROAD NO-111,FLAT-A,ABC LANE, A B C D ...... DHAKA
KOLKATA BANGLADESH
Phone +91000000000000 017000000000
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.
..……………………………………
12-JAN-2016
Date :………………………. SIGNATURE MUST BE SAME
Applicant’s signature (as in Passport)
AS IN PASSPORT
