ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

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Size: 2” X 2”

Visa Application Form

Signature
BGDKV04BBE20

A. Personal Particulars (As in Passport)

Surname (As in Passport) BISWAS
Given Nam e (As in Passport) NIKHIL KUMAR
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 25-AUG-1962 Religion HINDU
Application Id :BGDKV04BBE20

Place of Birth Town/City NARAIL Country of Birth BANGLADESH

Citizenship /National ID No 4792106081670 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. BT0017201 Date of issue ( dd/mm/yyyy ) 10-MAR-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 09-MAR-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 AF6120862 Date of issue(dd/mm/yyyy) 13-MAR-2013
Web Registration Date : 25-FEB-2020

Nationality/status BANGLADESH
C. Applicant’s Contact Details

40/5, PABLA MODHAPARA Phone No 01712202335

Present
address DAULATPUR, DAULATPUR Mobile /Cell No 1712202335
KHULNA, BANGLADESH 9202 Email address

Permanent 40/5, PABLA MODHAPARA

Address DAULATPUR, DAULATPUR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s NIRMOLESH CHANDRA BISWAS BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s RENUCA BISWAS BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse MONJU RANI BISWAS 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 MEDICAL VISA No of Entries MULTIPLE

Period of Visa ( Month) 12 Month Expected Date of Journey 17-MAR-2020
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

NIKHIL KUMAR BISWAS

 Required Detail of MEDICAL VISA
Hospital Name SANKARA NETHRALAYA KHULNA MEDICAL COLLEGE HOSPITAL
Address PREMISES NO-25-3333, PLOT NO-DJ16, KOLKATA-700156 BOYRA, SONADANGA, KHULNA-9000
Doctor Name TAMONASH BASU PROFESSOR DR JALAL AHMED
Phone/Fax 03330416000 +8801729953789
Details GLAUCOMA

Purpose of Visit : FOR PATIENTS

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in ASHOK KUMAR BISWAS
India
PATHARGHATA, RAJARHAT, NORTH 24 PGS, WB.

Application Id :BGDKV04BBE20
Cities in India Visited KOLKATA
Type of Visa MEDICAL VISA Visa Number VL2168548
Visa Issued Place DHAKA Date of Issue 06-AUG-2019
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 UNIT MANAGER
Employer name/business RHSTEP ALOR DHARA PATHSHALA
Employer Address 718, JESSORE ROAD, DAULATPUR, KHULNA
Phone Number
+88041763129
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 ASHOK KUMAR BISWAS MONJU RANI BISWAS
Address PATHARGHATA, RAJARHAT 40/5, PABLA MODHAPARA
NORTH 24 PGS, WB. DAULATPUR, KHULNA
Phone
00919775644312 01712202335
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)