ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDKV04BE220

A. Personal Particulars (As in Passport)

Surname (As in Passport) AZIM
Given Nam e (As in Passport) MD RASEL AL
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 08-FEB-1975 Religion ISLAM
Application Id :BGDKV04BE220

Place of Birth Town/City KHULNA Country of Birth BANGLADESH

Citizenship /National ID No 19754795130020440 Educational Qualification HIGHER SECONDARY
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BR0548533 Date of issue ( dd/mm/yyyy ) 21-JAN-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 20-JAN-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 : 25-FEB-2020

Nationality/status
C. Applicant’s Contact Details

24/2, B M C QUARTER, CHANMARI Phone No 01714253900

Present
address KHULNA SHIPYARD, KHULNA SADAR Mobile /Cell No 1714253900
KHULNA, BANGLADESH 9201 Email address

Permanent 24/2, B M C QUARTER, CHANMARI

Address KHULNA SHIPYARD, KHULNA SADAR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s AMIR ALI BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s ANOWARA BEGUM BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse TASLIMA AZIM 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 25-MAR-2020
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

MD RASEL AL AZIM
 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 :BGDKV04BE220
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 PRIVATE SERVICE Designation/Rank MANAGER
Employer name/business MESSRS RANA FISH AGENCY
Employer Address NOTUN BAZAR LAUNCH GHAT ROAD, KHULNA
Phone Number
+88041725065
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 TASLIMA AZIM
Address PATHARGHATA, RAJARHAT 24/2, B M C QUARTER, CHANMARI
NORTH 24 PGS, WB KHULNA SADAR, KHULNA
Phone
00919748693833 01714253900
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.

..……………………………………
25-FEB-2020
Date :………………………. Applicant’s signature (as in Passport)