APPLICATION FORM
( Registration )
13012537MBB4
Application ID No. 13012537MBB4 Final Submission Date Mon Jan 13 10:31:36 IST 2025
FOR OFFICE USE ONLY
Reg. No. S 1 1 2 B G D 2 0 2 5
Personal Details
Surname BEGUM
Given Name ANILA Paste your
Sex Female Date of Birth 08/10/1978 Height (in cm) 0 Recent passport size
Age as on today Year(s) 46 Month(s) 3 Day(s) 5 photograph here
Place of Birth KHULNA,KHULNA,BANGLADESH
Father's Name HAZI IQBAL
Mother's Name
Spouse's Name
Religion ISLAM Any Identification mark(s) preferably MOLE
visible
Present nationality BANGLADESH Previous nationality
Manner of acquiring present nationality Birth
Date of acquiring present nationality
Whether holding dual NO
nationality? If yes, Name of the country of second nationality
provide the following:- Passport No. of second country
Date of Issue
Date of Expiry
Whether travelled on this passport earlier to
India
Whether person of Indian Origin NO
Address of last residence (Outside India)
Address 72,CEMETRY ROAD,KHULNA SADAR,KHULNA SADAR-9100
City KHULNA Country BANGLADESH
Address intended for longer stay in India (Registration)
Address P/23,GURU TEG BAHADUR NAGAR,NEW PURENA WARD NO 45
City/ District RAIPUR State CHHATTISGARH
Pin Code 492001
Phone Number Mobile Number
Any Other Address in India
Address
City/ District State
Pin Code
Phone Number Mobile Number
Email/Occupation/Profession Details
E-Mail Id southdreamkolkata@gmail.com
Profession/Occupation BUSINESS
Passport Details
Passport Number A05666468 Place of Issue BANGLADESH, DHAKA
Date of Issue 27/11/2022 Expiry Date 26/11/2032
Visa Details
Visa Number VL6656142 Place of Issue BANGLADESH, DHAKA
Date of Issue 29/02/2024 Expiry Date 27/02/2025
Valid For Multiple Entry Visa Type TOURIST VISA
Special endorsement, if any
Organization/Company/Institute/Hospital Details
Name
Address
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13012537MBB4
Application ID No. 13012537MBB4
State City
Telephone Number Email ID
Employer EPFO ID Establishment ID
Arrival Details
Place of embarkation/boarding for India DHAKA,DHAKA,BANGLADESH
Date of arrival in India 06/01/2025
Place of disembarkation/arrival in India CHANGRABANDHA
Mode of Journey Road Flight/ Ship/ Bus/ Train No.
Purpose of visit to India Others
Previous Registration Details in India
Registration Number Place of Registration Visa Type Duration From To
Details of family members/attendant/dependents, if any accompanying.
Name Nationality Passport Number Relationship
Person to be contacted in Case of Emergency
Name ARMAN NIZAM THARA Relationship SON IN LAW
Address P/23,GURU TEG BAHADUR NAGAR,NEW PURENA City RAIPUR
WARD NO 45
Country INDIA Phone Number
Category Others
Military service details
Organisation Designation
Rank Place of Last Posting
Country of Last Posting
Signature of the Applicant
Date_ _ _ _ _ _ _ _ _ _ _ _ _
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13012537MBB4
Application ID No. 13012537MBB4
List of mandatory and non mandatory documents
Mandatory Documents.
1. Photo : Applicant's Photo
2. Residence proof : Residence proof i.e. updated form 'C' generated by hotel/ lodge or Registered / Notarized Lease Deed or Utility Bill copy along with copy of photo-ID of landlord with
declaration.
3. Visa : Copy of latest Indian visa
4. Passport : Bio-data page of passport
Registration office address
Office Name : FRO RAIPUR
Address : office of SP , Raipur
City/District : RAIPUR
State : CHHATTISGARH
Pin Code : 492001
Phone Number : 2285004
Office opening time: 10.30 closing time: 17.30
There is no need to submit hard copy to concerned
FRRO/FRO
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