HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDDV239AB19

A. Personal Particulars (As in Passport)

Surname (As in Passport) KHAN
Given Nam e (As in Passport) MOHAMMAD SAROUR
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 12-JUL-1981 Religion ISLAM
Application Id :BGDDV239AB19

Place of Birth Town/City BAGERHAT Country of Birth BANGLADESH

Citizenship /National ID No 19810126001000001 Educational Qualification BELOW MATRICULATION
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BR0692889 Date of issue ( dd/mm/yyyy ) 07-FEB-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 06-FEB-2023
Any other Passport/Identity Certificate held (if yes ,please fill in the following) YES
Country of issue BANGLADESH Place of issue DHAKA
Passport/IC No AC9106592 Date of issue(dd/mm/yyyy) 05-APR-2012
Web Registration Date : 28-JAN-2019

Nationality/status BANGLADESH
C. Applicant’s Contact Details

DEANA DAKSHINPARA Phone No 01910009744

Present
address DAULATPUR Mobile /Cell No 1910009744
KHULNA, BANGLADESH 9202 Email address

Permanent BAROY KHALI

Address MORRELGANJ, MORRELGANJ
BAGERHAT

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
BAGERHAT
Father’s YOUSUB ALI KHAN BANGLADESH BANGLADESH BANGLADESH
BAGERHAT
Mother’s SONABORU BIBI BANGLADESH BANGLADESH BANGLADESH
BAGERHAT
Spouse RABAYA AKTER BANGLADESH BANGLADESH 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)

Type Of Visa Required TOURIST VISA No of Entries MULTIPLE

Period of Visa ( Month) 12 Month Expected Date of Journey 28-FEB-2019
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit BY AIR/ HARIDASPUR

MOHAMMAD SAROUR KHAN

 Required Detail of TOURIST VISA
Places to be Visited KOLKATA

Purpose of Visit : INDIVIDUAL TOURIST

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in MD LIAKAT HOSSAIN
India
PATHARGHATA, RAJARHAT, NORTH 24 PGS, WB

Application Id :BGDDV239AB19
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VK0590216
Visa Issued Place DHAKA Date of Issue 24-JAN-2016
Countries visited in last 10 years
INDIA
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 PRIVATE SERVICE Designation/Rank SALESMAN
Employer name/business MESSRS SULTANA TRADING
Employer Address 59/19, OLD JESSORE ROAD, KHALISHPUR, KHULNA
Phone Number
+8801712886882
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 PATHARGHATA RAJARHAT NORTH 24 PARGANAS WEST BENGAL. 00919775644312,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e MD LIAKAT HOSSAIN RABAYA AKTER
Address PATHARGHATA, RAJARHAT DEANA DAKSHINPARA
NORTH 24 PGS, WB DAULATPUR, KHULNA
Phone
00919775644312 01910009744
Number

J. 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.

..……………………………………
28-JAN-2019
Date :………………………. Applicant’s signature (as in Passport)