ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDKV0521320

A. Personal Particulars (As in Passport)

Surname (As in Passport) JAHAN
Given Nam e (As in Passport) NUSRATH
Previous/other Name if any
Sex FEMALE Marital Status SINGLE
Date of birth 05-NOV-1991 Religion ISLAM
KHULNA BANGLADESH
Application Id :BGDKV0521320

Place of Birth Town/City Country of Birth

Citizenship /National ID No 4625855921 Educational Qualification GRADUATE
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BW0480475 Date of issue ( dd/mm/yyyy ) 19-JUN-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 18-JUN-2023
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 : 01-MAR-2020

Nationality/status
C. Applicant’s Contact Details

86, GOALKHALI MAIN ROAD Phone No 01931988309

Present
address KHULNA GPO, KHALISHPUR Mobile /Cell No 1931988309
KHULNA, BANGLADESH 9000 Email address

Permanent 86, GOALKHALI MAIN ROAD

Address KHULNA GPO, KHALISHPUR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s SK ABDUL QUADER BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s NASIMA KHATUN BANGLADESH BANGLADESH BANGLADESH

Spouse

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 30-MAR-2020
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

NUSRATH JAHAN
 Required Detail of TOURIST VISA
Places to be Visited KOLKATA

Purpose of Visit : FOR RECREATION,SIGHT SEEING, CASUAL VISIT TO MEET FRIENDS OR RELATIVES, ATTENDING A SHORT TERM YOG
F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India
,

Application Id :BGDKV0521320
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
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 HOUSEHOLD WORK Designation/Rank HOUSEHOLD WORK
Employer name/business NUSRATH JAHAN
Employer Address 86, GOALKHALI MAIN ROAD, KHALISHPUR, 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 Phone No.
1 PATHARGHATA RAJARHAT NORTH 24 PARGANAS WEST BENGAL. 00919748693833,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e MD LIAKAT HOSSAIN SK ABDUL QUADER
Address PATHARGHATA, RAJARHAT 86, GOALKHALI MAIN ROAD
NORTH 24 PGS, WB KHALISHPUR, KHULNA
Phone
00919748693833 01923970160
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.

..……………………………………
01-MAR-2020
Date :………………………. Applicant’s signature (as in Passport)