ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDKV0481720

A. Personal Particulars (As in Passport)

Surname (As in Passport) MALLICK
Given Name (As in Passport) ABDULKHALEK
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 05-FEB-1970 Religion ISLAM
JHALAKATI BANGLADESH
Application Id :BGDKV0481720

Place of Birth Town/City Country of Birth

Citizenship /National ID No 9136023224 Educational Qualification BELOW MATRICULATION
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BT0184838 Date of issue ( dd/mm/yyyy ) 28-MAR-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 27-MAR-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 : 23-FEB-2020

Nationality/status
C. Applicant’s Contact Details

MAHESHWAR PASA, PASCHIM PARA Phone No 01715780887

Present
address BIT, DAULATPUR Mobile /Cell No 1715780887
KHULNA, BANGLADESH 9203 Email address

Permanent MAHESHWAR PASA, PASCHIM PARA

Address BIT, DAULATPUR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
JHALAKATI
Father’s NAZEM MALLICK BANGLADESH BANGLADESH BANGLADESH
JHALAKATI
Mother’s CHAN BARU BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse TAHAMINA BEGUM 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 07-MAR-2020
Port Of Arrival BY ROAD GHOJADANGA Port of Exit BY ROAD GHOJADANGA

ABDULKHALEK MALLICK
 Required Detail of MEDICAL VISA
Hospital Name CHRISTIAN MEDICAL COLLEGE AND HOSPITAL CITY HEART DIAGNOSTIC & CONSULTATION CENTRE
Address IDA SCUDDER ROAD, VELLORE,TAMIL NADU-632004, INDIA 43, KDA AVENUE, MOYLAPOTA, KHULNA-9100
Doctor Name DR GIGI VARGHESE PROFESSOR DR S M ABDUL WAHAB
Phone/Fax +914162281000 +8801760812222
Details CANCER

Purpose of Visit : FOR PATIENTS

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in MD LIAKAT HOSSAIN
India
PATHARGHATA, RAJARHAT, NORTH 24 PGS, WB

Application Id :BGDKV0481720
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VL2448642
Visa Issued Place DHAKA Date of Issue 17-FEB-2020
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 BUSINESS PERSON Designation/Rank PROPRIETOR
Employer name/business MESSRS KHALEK FOOD PRODUCTS
Employer Address JABDIPUR, KHAN JAHAN ALI, 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 TAHAMINA BEGUM
Address PATHARGHATA, RAJARHAT MAHESHWAR PASA, BIT
NORTH 24 PGS, WB DAULATPUR, KHULNA
Phone
00919748693833 01936112377
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.

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