ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDKV053EB20

A. Personal Particulars (As in Passport)

Surname (As in Passport) AZAD
Given Nam e (As in Passport) MD ABUL KALAM
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 14-APR-1979 Religion ISLAM
Application Id :BGDKV053EB20

Place of Birth Town/City KHULNA Country of Birth BANGLADESH

Citizenship /National ID No 19794792103043183 Educational Qualification GRADUATE
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BX0219834 Date of issue ( dd/mm/yyyy ) 27-SEP-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 26-SEP-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 AF0915329 Date of issue(dd/mm/yyyy) 18-AUG-2013
Web Registration Date : 02-MAR-2020

Nationality/status BANGLADESH
C. Applicant’s Contact Details

MOHESWAR PASHA, KARTICKUL MAIN ROAD Phone No 01711261204

Present
address BIT, DAULATPUR Mobile /Cell No 1711261204
KHULNA, BANGLADESH 9203 Email address

Permanent MOHESWAR PASHA, KARTICKUL MAIN ROAD

Address BIT, DAULATPUR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s MD SHAHADAT FAKIR BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s MOMENA BEGUM BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse MOST TAHARIA SULTANA 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 BUSINESS VISA No of Entries MULTIPLE

Period of Visa ( Month) 60 Month Expected Date of Journey 30-MAR-2020
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

MD ABUL KALAM AZAD

 Required Detail of BUSINESS VISA
Company Name PASHUPATI ENTERPRISE
Address KUTHIBARI, BONGAON, NORTH 24 PGS, WB, INDIA
Phone 03215255461
Email

Purpose of Visit : FOR THOSE COMING TO ESTABLISH AN INDUSTRIAL/BUSINESS VENTURE, THOSE REQUIRED TO TRAVEL FREQUENTL
F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in HOTEL ORIENTAL
India
9/A, MARQUIS STREET, KOLKATA-700016

Application Id :BGDKV053EB20
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VL1879713
Visa Issued Place DHAKA Date of Issue 04-MAR-2019
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 BUSINESS MANAGER
Employer name/business ARMAN JUTE TRADING
Employer Address KHAN-A-SABUR ROAD, DAULATPUR, KHULNA
Phone Number
+8801715568622
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 ORIENTAL 9/A, MARQUIS STREET KOLKATA WEST BENGAL. 033-25855033,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e HOTEL ORIENTAL MOST TAHARIA SULTANA
Address 9/A, MARQUIS STREET MOHESWAR PASHA, BIT
KOLKATA-700016 DAULATPUR, KHULNA
Phone
033-25855033 01711261204
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)