HIGH COMMISSION OF INDIA
DHAKA(BANGLADESH) Paste your unsigned
recent color photograph.
Size: 2” X 2”
Visa Application Form
Signature
BGDDXECD4C17
A. Personal Particulars (As in Passport)
Surname (As in Passport) OBAYEDULLAH
Given Nam e (As in Passport) MD
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 02-JUL-1978 Religion ISLAM
Application Id :BGDDXECD4C17
Place of Birth Town/City KHULNA Country of Birth BANGLADESH
Citizenship /National ID No 19782690421361358 Educational Qualification POST GRADUATE
Visible identification marks CUT MARK ON EYEBROW
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BP0732983 Date of issue ( dd/mm/yyyy ) 18-JUL-2017
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 17-JUL-2022
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)
Web Registration Date : 27-DEC-2017
Nationality/status
C. Applicant’s Contact Details
PLOT A17, ROAD 6, BLOCK A, BANASREE Phone No
Present
address DHAKA Mobile /Cell No1713011445
DHAKA, BANGLADESH 1212 Email address
[email protected] Permanent NALIAN
Address NOLIYAN
KHULNA
D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s SHAHABUDDIN GAZI BANGLADESH BANGLADESH
KHULNA
Mother’s HAZERA BEGOM BANGLADESH BANGLADESH
KHULNA
Spouse KAZI UMMA ROMAN 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 24-JAN-2018
Port Of Arrival BY ROAD CHANGRABANDHA Port of Exit BY ROAD CHANGRABANDHA
MD OBAYEDULLAH
Required Detail of TOURIST VISA
Places to be Visited DARJEELING
Purpose of Visit : TOURISM
F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in 36, DR. SUDHIR BASU ROAD, KHIDERPUR
India
KOLKATA,
Application Id :BGDDXECD4C17
Cities in India Visited KOLKATA DELHI
Type of Visa TOURIST VISA Visa Number G995493
Visa Issued Place DHAKA Date of Issue 28-AUG-2002
Countries visited in last 10 years
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 SINIOR IT AND COMMUNICATION ADMINISTRATOR
Employer name/business ASIA ENERGY CORPORATION BANGLADESH PTY LTD
Employer Address PLOT 2A, BLOCK SEC, ROAD 138, GULSHAN 1
Phone Number
9850205
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 GOLDEN WIND HORSE TN ROAD DARJILING WEST BENGAL. 0354-2251070,
[email protected]2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e GOLDEN WIND HORSE ROUSHAN KAMAL
Address T.N ROAD NEAR SHERPA 26/7, SUKRABAD, DHAKA 1207
CHOWRASTA,DARJEELING
Phone
0354-2251070 01730076251
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.
..……………………………………
27-DEC-2017
Date :………………………. Applicant’s signature (as in Passport)
