ASST HIGH COMMISSION OF INDIA RAJSHAHI

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Visa Application Form

Signature
BGDR86118116

A. Personal Particulars (As in Passport)

Surname (As in Passport) MOLLAH
Application Id : BGDR86118116

Given Name (As in Passport) MD AKHERUZZAMAN

Previous/other Name if any Not Applicable

Appointment Date : 04-MAY-2017 At : 8.45 Hrs.

Gender MALE Marital Status MARRIED
Date of Birth 01-OCT-1969 Religion ISLAM
Place of Birth Town/City NAOGAON Country of Birth BANGLADESH
Citizenship /National ID No 19696414794915889 Educational Qualification HIGHER SECONDARY
Visible identification marks NA
Current Nationality Nationality by Birth/
BANGLADESH Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. BM0792403 Date of Issue ( dd/mm/yyyy ) 11-DEC-2016
Place of Issue NAOGAON Date of Expiry ( dd/mm/yyyy ) 10-DEC-2021
NO
Web Registration Date : 30-DEC-2016

Any other Passport/Identity Certificate held (if yes ,please fill in the following)
Country of Issue Place of Issue
Passport/IC No. Date of issue (dd/mm/yyyy)
Nationality/Status
C. Applicant's Contact Details
Present SINGA Phone No 01713788702
Address SINGA Mobile /Cell No 1720535255
NAOGAON, BANGLADESH 6511 Email address

Permanent SINGA
Address SINGA
NAOGAON

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
NAOGAON
Father's AHSAN MOLLAH BANGLADESH BANGLADESH BANGLADESH
NAOGAON
Mother's FIROZA BEOA BANGLADESH BANGLADESH BANGLADESH
NAOGAON
Spouse MRS SHAHANAJ JAMAN BANGLADESH BANGLADESH BANGLADESH
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

MD AKHERUZZAMAN MOLLAH
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) 24 Month Expected Date of Journey 15-FEB-2017
BY RAIL GEDE/BYROAD BY RAIL GEDE/BYROAD
Port Of Arrival HARIDASPUR Port of Exit HARIDASPUR
Required Detail of TOURIST VISA
Places to be Visited

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in KOLKATA
India HGFG ,
Cities in India Visited KOLKATA, CHENNAI
Type of Visa TOURIST VISA Visa Number VJ7674819
Visa Issued Place RAJSHAHI Date of Issue 14-MAY-2015
Countries visited in last 10
years INDIA

Application Id : BGDR86118116
Have you been refused an Indian Visa or extension of the same previously or deported
from India ? NO
G. Profession/Occupation Details :
Present Occupation BUSINESS PERSON Designation/Rank OWNER
Employer name/business FIROZA TRADERS
Employer Address SABAIHAT, TENTULIA MANDA, NAOGAON
Phone Number 01716726307
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 ESPLANADE CHAMBERS CHANDNI CHOWK STREET 2 ND FLOOR KOLKATA WEST BENGAL. +91 33 2212 710,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Name ALAMGIR ALI MOKLESUR RAHMAN MOLLAH
INDIA EXCHANGE PL RD,
Address LAL BAZAR FIROZA JEWELLERS
BARABAZAR MARKET,
KOLKATA RAJSHAHI RANIBAZAR
Phone Number +919831134786 01712943234
K. 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.

30-DEC-2016 ................................
Date : ...................... Applicant's signature (as in Passport)