ffi HIGH CO},IMTSSION OF IIIDIA

Signature
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BGDDVE1AE222

N Surname (As in Passport)

N civen Name (As in Passpon)
N ABDUS
L! Previouslother Name if any Not Applicable

L! Gender MALE Marital Status SINGLE

Date of Binh 22-MAR-1999 Religion ISLAM
o
o
(,
Place of Birth Town/City GOPALGANJ Counby of Birth BANGLADESH
co Citizenship, ational lD No 7354212234 EducationalQualification GRADUATE
Visible identirication marks NIL
E
Current Nationality Nationality by Birrw
; BANGLADESH Naturalization BY BIRTH
'r=
o Any Other PreviouslPast Nationalily Nor Appticabte
i= B. Passpofl Details
o-
o- Passport No. A04816538 Date of lssue ( ddimm/yyyy i 21"5EP.2022
Place of lssue
-DHAKA Date of Expiry ( dd/mm/yyyy ) 20-sEP-2032
N Any other Passport/ldentity Certificate held (if yes ,please fill in the following) NO
N Country of lssue
N -Place of lssue
PassporUlC No. Date of issue (ddlmmry)ryy)
o
z NationalitylStatus
C. Applkxm s Cor|ract lretaiE
N
Present H/F#DAG.196 Phone No
6) Address UTTAR BADDA Mobile /Cell No 89017 6662317 7
(o
Email address
o DHAKA, BANGTADESH 1212 MSSABSAMAD@GIUAIL.COM

Permanent BYASPUR, BYASPUR

'j=
(E Address KASHIANI, JONAPUR-81 33

.9.
0) D. Family Details
GOPALGANJ
rffiffiffiffiffiffiffiffi]ilt
u.
Relation ame ilrtionality Prev. alk nality Placercountry of
0)
GOPALGANJ
Father's ABDUS SATTAR BANGLI.DESH BANGLADESH
= GOPALGAN]
Mother's .DOLENA BEGUM BANGLI,DESH BANGLADESH
Marital
Status Single
were your G.andfather/Grandmother(Paternalniatemal) Pakistan Nationals Or belong to Pakistan held area : NO

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ABDUS SAMAD
E. Det ils ot visa Sought (Visa shall b€ valid trorn the Date of lssu€ and not fronr the Date of Journey)
Type Of Visa Required TOURIST VISA No ol Entries MULTIPLE
Period of Visa ( Month) 12 Month Oate of Journey
Pon Of Arrival Pon of Exit
Requifed Derail ol
TouRlsT vlsA
Places to b€ visited KOLKATA

Have You Ever visited lndia ? NO

Address where You stayed in
lndaa
Cities in lndia Visited
Type of Visa visa Number
Visa lssued Place Date of lssue
Countries visited in last 10
years
**sed an lndian Visa or extension of tlre same previously or d€Poned N
N
ll3li trr,"Y. NO (\
l!
Present Occupation PRIVATE SERVICE Oesignation/Rank SALES EXECUTIVE
trl
Employername/business BKENTERPRISE
o
Employer Address
Phone Number 234/D, ELEPHANT ROAD, BANASREE, DHAKA 1219
o
L9
Past occupation if any T
Are/have you worked with Ann€d forces/ PoliceJ Para i,lilitary forces ? NO
Organization Designation ;
Place of Posting Rank '-(g
H. Address of Place of St y/Holet .9
o o-
Place/Hotel Na]ne Address of Place, Hotel stat€ Phon€ : o-
1 HOTEL NEW TIGER INN 1O/C, MRIGENDRALAL MITTER RD, iIASKARHAT I(OLKATA WEST BENGAL. +9170651'I1128,
,
3 .,
4
l. Details ol Two R€ferenca
h lnd. In BANGLADESH

Name HOTEL NEW TIGER INN

MRIGENDRALAL
1CI/C,
Address MITTER RD JONAPUR-8133
,T KOLKATA
BENGAL GOPALGANJ
Phone Numb€r +917065111',I28 +880] 792106382
t(. OECLARATIOI{
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 lndia and and able to abide fully bY them.
c I declare that the information given in the form is complete and lndia will be undenaken for the purPose
indicated in the application.
d. lundersland thal in case the information provided in ahe be liable for denial of visiu entry or
depo(ation and/ or other penalties during the visit as P(ovl
e. I will also submit hard-copy all the uploaded docur to the corrceming lndian
irrssron or Agency for processing ot visa application.

I 2-t!aov-2022 ::{13{lls-..
Date: ......-............... Applicant's signature (as in passpon)
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