ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDKV04A3220

A. Personal Particulars (As in Passport)

Surname (As in Passport) TALUKDER
Given Nam e (As in Passport) IBRAHIM
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 12-FEB-1973 Religion ISLAM
Application Id :BGDKV04A3220

Place of Birth Town/City BAGERHAT Country of Birth BANGLADESH

Citizenship /National ID No 0116059831032 Educational Qualification BELOW MATRICULATION
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BQ0208064 Date of issue ( dd/mm/yyyy ) 07-SEP-2017
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 06-SEP-2022
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)
Web Registration Date : 24-FEB-2020

Nationality/status
C. Applicant’s Contact Details

MANIKJOR Phone No 01832405911

Present
address AMTOLI BAZAR, MORRELGANJ Mobile /Cell No 1832405911
BAGERHAT, BANGLADESH 9320 Email address

Permanent MANIKJOR
Address AMTOLI BAZAR, MORRELGANJ
BAGERHAT

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
BAGERHAT
Father’s MD MUZIBAR TALUKDER BANGLADESH BANGLADESH BANGLADESH
BAGERHAT
Mother’s SAMSUN NAHAR BANGLADESH BANGLADESH BANGLADESH
BAGERHAT
Spouse MOHIMA BEGUM 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 25-MAR-2020
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

IBRAHIM TALUKDER
 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 MD LIAKAT HOSSAIN
India
PATHARGHATA, RAJARHAT, NORTH 24 PGS, WB

Application Id :BGDKV04A3220
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VL2435971
Visa Issued Place DHAKA Date of Issue 26-DEC-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 FARMER Designation/Rank FARMER
Employer name/business IBRAHIM TALUKDER
Employer Address MANIKJOR, AMTOLI BAZAR, MORRELGANJ, BAGERHAT
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 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 MD LIAKAT HOSSAIN MOHIMA BEGUM
Address PATHARGHATA, RAJARHAT MANIKJOR, AMTOLI BAZAR
NORTH 24 PGS, WB MORRELGANJ, BAGERHAT
Phone
00919775644312 01924184267
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.

..……………………………………
24-FEB-2020
Date :………………………. Applicant’s signature (as in Passport)