HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDDV84F8418

A. Personal Particulars (As in Passport)

Appointment Date : 20-MAR-2018 At : 8.30 Hrs.

Surname (As in Passport) DAS
Given Nam e (As in Passport) ARJUN
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 15-FEB-1972 Religion HINDU
Application Id :BGDDV84F8418

Place of Birth Town/City KHULNA Country of Birth BANGLADESH

Citizenship /National ID No 19724795127476921 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. BF0365267 Date of issue ( dd/mm/yyyy ) 05-MAY-2015
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 04-MAY-2020
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 : 11-MAR-2018

Nationality/status

Khulna
C. Applicant’s Contact Details

18, MISTRYPARA KHALPAR ROAD Phone No 01711052854

Present
address KHULNA GPO, KHULNA SADAR Mobile /Cell No 1763370782
KHULNA, BANGLADESH 9100 Email address

Permanent 18, MISTRYPARA KHALPAR ROAD

Address KHULNA
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s KARTICK CHANDRO DAS BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s KALYANI DAS BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse KRISHNA DAS 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 31-MAR-2018
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit BY AIR/ HARIDASPUR

ARJUN DAS
 Required Detail of TOURIST VISA
Places to be Visited BARASAT, NOWAPARA
N24PGS, WB

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in BARASAT, NOWAPARA
India
N24PGS, WB,

Application Id :BGDDV84F8418
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VK4259565
Visa Issued Place DHAKA Date of Issue 02-NOV-2016
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 TONNI PRODUCTS
Employer Address 46, JAHIDUR RAHAMAN ROAD, KHULNA
Phone Number
01711052854
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 HOTEL DIPLOMAT 10,SADDER STREET KOLKATA WEST BENGAL. 00919830504248,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e RAKESH SARKAR KRISHNA DAS
Address BARASAT, NOWAPARA 18, MISTRYPARA KHALPAR ROAD
N24PGS, WB KHULNA GPO, KHULNA SADAR, KHULNA
Phone
918337020999 01711052854
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.

..……………………………………
11-MAR-2018
Date :………………………. Applicant’s signature (as in Passport)