High Commission of India

Dhaka

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REQUEST FOR SPECIAL PERMIT (FOR RESTRICTED AND PROTECTED

AREAS)

1. Name of applicant ( Mr./Mrs./Ms.) _________________________________

(in capital letters with surname underlined)

PHOTOGRAPH

2. Father's / Mother’s name ________________________

3. Father’s/ Mother’s nationality _____________________________________

4. Surname at birth; if different_____________________________________

5. Place & Date of Birth(Name of Town & Country)______________________

6. Nationality :

(a) Present__________________________________________________

(b) Past, if different & till which date____________________________

(c) Reason for change_________________________________________

7. Occupation____________________________________________________

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8. Permanent Address_____________________________________________

9. Mailing address in India, if any_________________________________

_____________________________________________________________

10. Contact number and Email ID : Contact number : _______________

Email ID : ___________________

Photograph

11. References :

(a) In country of applicant_____________________________________

(b) India__________________________________________________

12. Passport details :

Number____________________________________________________

Issued by____________________________________________________

At__________________________________________________________

Valid upto____________________________________________________

13. Details of visa for India, if any obtained :

Issued by ___________________________________________________

Number_______________________________________________________

at___________________________________________________________

Valid upto____________________________________________________

14. Places proposed to be visited______________________________________

15. Route intended to be followed___________________________________

16. Purpose of visit________________________________________________

17. Likely date of visit_______________________________________________

18. Likely duration of visit___________________________________________

19. Is any one accompanying the applicant?_____________________________

If so, please give details_________________________________________

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20. Arrangements for travel and accommodation

that may have been made_______________________________________

21. Details of previous visit to India_________________________________

22. Whether previously visited any restricted/

protected area in India?_____________________________________

If so, please give detail of the places

visited and the date of visit_______________________________________

23. Has any earlier request for permits been refused?___________________

If so, please furnish details_______________________________________

DECLARATION

The information given above is correct and complete to the best of

my knowledge.

Place_______________________

Date________________________ (Signature of Applicant)