ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDKV06CE720

A. Personal Particulars (As in Passport)

Surname (As in Passport) PAUL
Given Nam e (As in Passport) ABANI MOHON
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 01-AUG-1943 Religion HINDU
Application Id :BGDKV06CE720

Place of Birth Town/City BAGERHAT Country of Birth BANGLADESH

Citizenship /National ID No 3734722360 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. BW0557668 Date of issue ( dd/mm/yyyy ) 24-JUN-2018
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 23-JUN-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 AF0483839 Date of issue(dd/mm/yyyy) 30-MAY-2013
Web Registration Date : 28-NOV-2020

Nationality/status BANGLADESH
C. Applicant’s Contact Details

HARIKHALI, MADHYAPARA PRIMARY Phone No 01710900011

Present
address SCHOOL ROAD, PC COLLEGE Mobile /Cell No 1710900011
BAGERHAT SADAR, BAGERHAT, BANGLADESH 9301 Email address

Permanent HARIKHALI, MADHYAPARA PRIMARY

Address SCHOOL ROAD, PC COLLEGE
BAGERHAT SADAR, BAGERHAT

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
BAGERHAT
Father’s TARINI KANTA PAUL BANGLADESH BANGLADESH BANGLADESH
BAGERHAT
Mother’s MANOMOHINI PAUL BANGLADESH BANGLADESH BANGLADESH
BAGERHAT
Spouse PUSPA SREE PAUL 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) 6 Month Expected Date of Journey 21-DEC-2020
Port Of Arrival BY ROAD HARIDASPUR Port of Exit BY ROAD HARIDASPUR

ABANI MOHON PAUL

 Required Detail of MEDICAL VISA
Hospital Name FORTIS HOSPITAL CITYLAB DIAGNOSTIC & SPECIALIZED CONSUL. CENTER
Address 730, ANANDAPUR, E.M. BYPASS ROAD, KOLKATA-700107 SHAHID MINAR ROAD, BAGERHAT
Doctor Name DR DIBYENDU MUKHERJEE DR SAID AHMED
Phone/Fax 033 6628 4444 +8801717704477
Details HEART BURN

Purpose of Visit : FOR PATIENTS

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

Application Id :BGDKV06CE720
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VK5978829
Visa Issued Place DHAKA Date of Issue 16-JUL-2017
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 FARMER Designation/Rank FARMER
Employer name/business ABANI MOHON PAUL
Employer Address HARIKHALI, PC COLLEGE, BAGERHAT SADAR, BAGERHAT
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 ASHOK KUMAR PAUL ALAKESH PAUL
Address PATHARGHATA, RAJARHAT HARIKHALI, PC COLLEGE
NORTH 24 PGS, WB BAGERHAT SADAR, BAGERHAT
Phone
00919748693833 01715145829
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.

..……………………………………
28-NOV-2020
Date :………………………. Applicant’s signature (as in Passport)