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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDY4986E16

Previous/other Name if any

FEMALE
18-MAY-1969
KHULNA
19694794512164277
NA
BANGLADESH

Sex

Web Registration Date : 07-SEP-2016

Application Id :BGDDY4986E16

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

Marital Status
Religion
Country of Birth
Educational Qualification

MARRIED
ISLAM
BANGLADESH
BELOW MATRICULATION

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

14-MAR-2016
13-MAR-2021

Any Other Previous/Past Nationality

B. Passport Details

BK0450767
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

HOUSE NO-S-64,146,KHULNA GPO,

KHALISHPUR
KHULNA,, BANGLADESH 9000

Phone No
Mobile /Cell No

01628781646
1616121240

Email address

Permanent HOUSE NO-S-64,146,KHULNA GPO,

Address
KHALISHPUR
KHULNA,
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

ABDUL KARIM

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Mothers

SOBRATAN BIBI

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Spouse

ZAKIR HOSSAIN

BANGLADESH

BANGLADESH

KHULNA
BANGLADESH

Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

E. Details of Visa Sought

TOURIST VISA
(Month) 12 Month
BY AIR/ HARIDASPUR

Type Of Visa Required

Period of Visa
Port Of Arrival

(Visa shall be valid from the Date of Issue and not from the Date of Journey)

ZAMILA KAHTUN

No of Entries
Expected Date of Journey
Port of Exit

MULTIPLE
29-SEP-2016
BY AIR/ HARIDASPUR

Appointment Date : 18-SEP-2016 At : 11.00

A. Personal Particulars (As in Passport)

Surname (As in Passport)
KAHTUN
Given Nam e (As in Passport) ZAMILA

Required Detail of

TOURIST VISA
KOLKATA GUEST HOUSE
37 KAVI MD IQBAL ROAD KOLKATA

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 Number
Visa Issued Place
Date of Issue
Countries visited in last 10 years
NO
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 of Spouse
Present Occupation HOUSE WIFE
Designation/Rank
HOUSE WIFE
Employer name/business ZAKIR HOSSAIN
Employer Address HOUSE NO-S-64,146,KHULNA GPO,, KHULNA
Phone Number
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
1 KOLKATA GUEST HOUSE 37 KAVI MD IQBAL ROAD KOLKATA KOLKATA WEST BENGAL. 009189784578515,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
SHUKDEV PAUL
Nam e KOLKATA GUEST HOUSE
Address 37 KAVI MD IQBAL ROAD
107 SIR IQBAL ROAD
KOLKATA

Phone
00919856298541
Number

Phone No.

KHULNA
01913711029

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.

07-SEP-2016
Date :.

..
Applicants signature (as in Passport)

Application Id :BGDDY4986E16

Places to be Visited