HIGH COMMISSION OF INDIA

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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDVE88F414

Web Registration Date : 24-AUG-2014

Web File Number :BGDDVE88F414

Previous/other Name if any

Sex
Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality

Male
10-APR-1958
SATKHIRA
2694263710439
NIL
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

Married
ISLAM
BANGLADESH
POST GRADUATE

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

08-JAN-2014
07-JAN-2019

Any Other Previous/Past Nationality

B. Passport Details

BA0184793
DHAKA

Passport No.
Place of issue

Date of expiry (dd/mm/yyyy)

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)

Nationality/status
C. Applicants Contact Details
Present
address

14/A, BUET STAFF QUARTER,

BUET, POSTA, LALBAGH,
DHAKA, BANGLADESH 0

Phone No

01199103783
Email address azizsirbuet@skype.com

Mobile /Cell No

Permanent KALIMAKHALI, NASIMABAD,

Address
ASHASHUNI,
SATKHIRA
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

MOHAMMAD NURUL HAQUE

BANGLADESH

BANGLADESH

SATKHIRA
BANGLADESH

Mothers

MISSES ASIA BEGUM

BANGLADESH

BANGLADESH

SATKHIRA
BANGLADESH

Spouse

REHANA AZIZ

BANGLADESH

BANGLADESH

SATKHIRA
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)

TOURIST VISA
(Month) 12 Month
BY AIR/ HARIDASPUR

Type Of Visa Required

Period of Visa
Port Of Arrival

MOHAMMAD AZIZUL HAQUE

No of Entries
Expected Date of Journey
Port of Exit

Multiple
30-AUG-2014
BY AIR/ HARIDASPUR

Appointment Date : 03-SEP-2014 At : 11.30

A. Personal Particulars (As in Passport)

Surname (As in Passport)
HAQUE
Given Nam e (As in Passport) MOHAMMAD AZIZUL

Required Detail of

TOURIST VISA
KOLKATA
INDIA

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India

NO

Cities in India Visited

Type of Visa
Visa Issued Place
Countries visited in last 10 years

Visa Number
Date of Issue

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 COLLEGE/UNIVERSITY TEACHER
Designation/Rank
LECTURER
Employer name/business NATIONAL INSTITUTE OF ENGINEERING & TECHNOLOGY
Employer Address RUPSHI, RUPGONJ, NARAYANGONJ
Phone Number
+88-04478912395

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 SAMRAT 23, MARQUISE STREET KOLKATA WEST BENGAL . 9432441963, null
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
Nam e HOTEL SAMRAT
REHANA AZIZ
Address 23, MARQUISE STREET
COMPTROLLER OFFICE BUET, POSTA,
KOLKATA- 700016

Phone
9432441963
Number

LALBAGH, DHAKA
01199103783

J. DECLARATION:
a.
b.
c.
d.

I do not hold any other passport(s) other than those detailed above.
I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them.
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.
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-AUG-2014
Date :.

..
Applicants signature (as in Passport)

Web File Number :BGDDVE88F414

Places to be Visited