HIGH COMMISSION OF INDIA
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DHAKA(BANGLADESH)
Visa Application Form
Signature
BGDDY4986E16
Previous/other Name if any
FEMALE
18-MAY-1969
KHULNA
19694794512164277
NA
BANGLADESH
Sex
Web Registration Date : 07-SEP-2016
Application Id :BGDDY4986E16
Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality
Marital Status
Religion
Country of Birth
Educational Qualification
MARRIED
ISLAM
BANGLADESH
BELOW MATRICULATION
Nationality by Birth/ Naturalization
BY BIRTH
Date of issue ( dd/mm/yyyy )
14-MAR-2016
13-MAR-2021
Any Other Previous/Past Nationality
B. Passport Details
BK0450767
DHAKA
Passport No.
Place of issue
Date of expiry (dd/mm/yyyy)
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. Applicants Contact Details
Present
address
HOUSE NO-S-64,146,KHULNA GPO,
KHALISHPUR
KHULNA,, BANGLADESH 9000
Phone No
Mobile /Cell No
01628781646
1616121240
Email address
Permanent HOUSE NO-S-64,146,KHULNA GPO,
Address
KHALISHPUR
KHULNA,
D. Family Details
Relation
Name
Nationality
Prev. Nationality
Place/Country of Birth
Fathers
ABDUL KARIM
BANGLADESH
BANGLADESH
KHULNA
BANGLADESH
Mothers
SOBRATAN BIBI
BANGLADESH
BANGLADESH
KHULNA
BANGLADESH
Spouse
ZAKIR HOSSAIN
BANGLADESH
BANGLADESH
KHULNA
BANGLADESH
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO
E. Details of Visa Sought
TOURIST VISA
(Month) 12 Month
BY AIR/ HARIDASPUR
Type Of Visa Required
Period of Visa
Port Of Arrival
(Visa shall be valid from the Date of Issue and not from the Date of Journey)
ZAMILA KAHTUN
No of Entries
Expected Date of Journey
Port of Exit
MULTIPLE
29-SEP-2016
BY AIR/ HARIDASPUR
Appointment Date : 18-SEP-2016 At : 11.00
A. Personal Particulars (As in Passport)
Surname (As in Passport)
KAHTUN
Given Nam e (As in Passport) ZAMILA
Required Detail of
TOURIST VISA
KOLKATA GUEST HOUSE
37 KAVI MD IQBAL ROAD KOLKATA
Purpose of Visit : TOURISM
F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India
NO
Cities in India Visited
Type of Visa
Visa Number
Visa Issued Place
Date of Issue
Countries visited in last 10 years
NO
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 of Spouse
Present Occupation HOUSE WIFE
Designation/Rank
HOUSE WIFE
Employer name/business ZAKIR HOSSAIN
Employer Address HOUSE NO-S-64,146,KHULNA GPO,, 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
1 KOLKATA GUEST HOUSE 37 KAVI MD IQBAL ROAD KOLKATA KOLKATA WEST BENGAL. 009189784578515,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
SHUKDEV PAUL
Nam e KOLKATA GUEST HOUSE
Address 37 KAVI MD IQBAL ROAD
107 SIR IQBAL ROAD
KOLKATA
Phone
00919856298541
Number
Phone No.
KHULNA
01913711029
J. DECLARATION:
a.
b.
c.
d.
I do not hold any other passport(s) other than those detailed above.
I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them.
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.
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.
07-SEP-2016
Date :.
..
Applicants signature (as in Passport)
Application Id :BGDDY4986E16
Places to be Visited
