ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

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Size: 2” X 2”

Visa Application Form

Signature
BGDKV053F820

A. Personal Particulars (As in Passport)

Surname (As in Passport) DAS
Given Nam e (As in Passport) DILIP
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 11-NOV-1965 Religion HINDU
KHULNA BANGLADESH
Application Id :BGDKV053F820

Place of Birth Town/City Country of Birth

Citizenship /National ID No 3732081538 Educational Qualification HIGHER SECONDARY
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BW0665802 Date of issue ( dd/mm/yyyy ) 01-JUL-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 30-JUN-2023
Any other Passport/Identity Certificate held (if yes ,please fill in the following) YES
Country of issue BANGLADESH Place of issue DHAKA
Passport/IC No AF4704343 Date of issue(dd/mm/yyyy) 14-JUL-2013
Web Registration Date : 02-MAR-2020

Nationality/status BANGLADESH
C. Applicant’s Contact Details

MOHESWARPASHA, SAHA PARA MAIN ROAD Phone No 01929919998

Present
address BIT, DAULATPUR Mobile /Cell No 1929919998
KHULNA, BANGLADESH 9203 Email address

Permanent MOHESWARPASHA, SAHA PARA MAIN ROAD

Address BIT, DAULATPUR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s SUBODH DAS BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s DULALI DAS BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse RUPA DAS 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 30-MAR-2020
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

DILIP DAS
 Required Detail of TOURIST VISA
Places to be Visited KOLKATA

Purpose of Visit : FOR RECREATION,SIGHT SEEING, CASUAL VISIT TO MEET FRIENDS OR RELATIVES, ATTENDING A SHORT TERM YOG
F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in ASHOK KUMAR DAS
India
PATHARGHATA, RAJARHAT, NORTH 24 PGS, WB

Application Id :BGDKV053F820
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VL1211394
Visa Issued Place DHAKA Date of Issue 22-NOV-2018
Countries visited in last 10 years
INDIA
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 MANAGER
Employer name/business S S ALI AND CO
Employer Address B J A BHABAN, 544 JESSORE ROAD, DAULATPUR, KHULNA
Phone Number
+8801712087561
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 PATHARGHATA RAJARHAT NORTH 24 PARGANAS WEST BENGAL. 00919748693833,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e ASHOK KUMAR DAS RUPA DAS
Address PATHARGHATA, RAJARHAT MOHESWARPASHA, BIT
NORTH 24 PGS, WB DAULATPUR, KHULNA
Phone
00919748693833 01929919998
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.

..……………………………………
02-MAR-2020
Date :………………………. Applicant’s signature (as in Passport)