ASSISTANT HIGH COMMISSION OF INDIA

CHITTAGONG(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDC06226921

A. Personal Particulars (As in Passport)

Surname (As in Passport) BISWAS
Application Id : BGDC06226921

Given Name (As in Passport) SOURAV

Previous/other Name if any Not Applicable
Gender MALE Marital Status SINGLE
Date of Birth 04-JAN-1993 Religion HINDU
Place of Birth Town/City CHATTOGRAM Country of Birth BANGLADESH
Citizenship /National ID No 19931591017000456 Educational Qualification POST GRADUATE
Visible identification marks A SMALL WHITE PORTION IN FACE
Current Nationality Nationality by Birth/
BANGLADESH Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. BX0388324 Date of Issue ( dd/mm/yyyy ) 13-OCT-2018
Place of Issue DIP DHAKA Date of Expiry ( dd/mm/yyyy ) 12-OCT-2023
NO
Web Registration Date : 16-DEC-2021

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
JAMAL VILA, HAJI MD JAMAL
Present UDDIN, Phone No 01818401855
Address K B AMAN ALI ROAD, BAKOLIA Mobile /Cell No
CHATTOGRAM, BANGLADESH
4203 Email address SOURAV.BISWAS41DU@GMAIL.COM

Permanent NORTH GUZARA, WARD NO: 01

Address THAKURBARI, RAOZAN
CHATTOGRAM

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
CHATTOGRAM
Father's ADHIR BISWAS BANGLADESH BANGLADESH
CHATTOGRAM
Mother's ARCHANA BISWAS BANGLADESH BANGLADESH
Marital
Status Single
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

SOURAV BISWAS
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 MEDICAL VISA No of Entries MULTIPLE
Period of Visa ( Month) 12 Month Expected Date of Journey 02-JAN-2022
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit BY AIR/ HARIDASPUR
Required Detail of MEDICAL VISA
Hospital Name KKR ENT HOSPITAL AND RESEARCH INSTITUTE
Address KILPAUK, CHENNAI
Doctor Name DR RAVI RAMALINGAM
Phone/Fax +91 44 26411444
Details HEARING LOSS AND TINNITUS
Purpose of Visit : FOR PATIENTS
F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in KKR ENT HOSPITAL AND RESEARCH INSTI
India KILPAUK, CHENNAI ,
Cities in India Visited KOLKATA, CHENNAI
Type of Visa MEDICAL VISA Visa Number VL5469192

Application Id : BGDC06226921
Visa Issued Place CHATTOGRAM Date of Issue 09-FEB-2021
Countries visited in last 10
years INDIA
Have you been refused an Indian Visa or extension of the same previously or deported
from India ? NO
G. Profession/Occupation Details :
Present Occupation DEPENDENT ON FATHER Designation/Rank ASSISTANT TEACHER
Employer name/business KALARPOLE HAJI OMRA MIA CHOWDHURY HIGH SCHOOL
Employer Address SHIKALBAHA, KARNAFULI, CHATTOGRAM
Phone Number 01834872212
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 GEMS FLAT THOUSAND LIGHTS CHENNAI TAMIL NADU. 9841135118,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Name DR RAVI RAMALINGAM DR ASHIM KUMAR BISWAS
KKR ENT HOSPITAL AND
Address RESEARCH INSTI BSMMU, SHAHBAG, DHAKA
KILPAUK CHENNAI TAMIL
NADU
Phone Number +91 44 26411444 01972224400
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.

16-DEC-2021 ................................
Date : ...................... Applicant's signature (as in Passport)