ASSISTANT HIGH COMMISSION OF INDIA

SYLHET(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDSV055DE19

A. Personal Particulars (As in Passport)

Surname (As in Passport) RASHID
Given Nam e (As in Passport) HARUNUR
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 01-JAN-1967 Religion ISLAM
Application Id :BGDSV055DE19

Place of Birth Town/City MOULVIBAZAR Country of Birth BANGLADESH

Citizenship /National ID No 5817414260457 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. BQ0597087 Date of issue ( dd/mm/yyyy ) 17-OCT-2017
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 16-OCT-2022
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 : 20-MAY-2019

Nationality/status
C. Applicant’s Contact Details

DOKIN CHOMATKKAR JAGATSHI Phone No +8801712252643

Present
address MOULVIBAZAR SADAR Mobile /Cell No 1712252643
MOULVIBAZAR, BANGLADESH 3200 Email address

Permanent DOKIN CHOMATKKAR JAGATSHI

Address MOULVIBAZAR SADAR
MOULVIBAZAR

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
MOULVIBAZAR
Father’s JEYA UDDIN BANGLADESH BANGLADESH BANGLADESH
MOULVIBAZAR
Mother’s SURATHUN NASSA BANGLADESH BANGLADESH BANGLADESH
MOULVIBAZAR
Spouse FATHEMA 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 14-JUN-2019
Port Of Arrival BY ROAD DAWKI Port of Exit BY ROAD DAWKI

HARUNUR RASHID
 Required Detail of MEDICAL VISA
Hospital Name NARAYANA HEALTH EDEN MULTI CARE HOSPITAL
Address BOMMASANDRA INDUSTRIAL AREA ANEKAL TALUK BANGALORE 753 SATMASJID ROAD DHANMONDI DHAKA
Doctor Name GAYATHRI GOPALKRISHNAN PROFESSOR AKM FAZLUL HAQUE
Phone/Fax 08071222222 58150507
Details GASTROENTEROLOGY

Purpose of Visit : MEDICAL TREATMENT OF SELF

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in NARAYANA HEALTH
India
BOMMASANDRA INDUSTRIAL AREA, ANEKAL TALUK

Application Id :BGDSV055DE19
Cities in India Visited BANGALORE
Type of Visa MEDICAL VISA Visa Number VK7318663
Visa Issued Place DHAKA Date of Issue 08-NOV-2017
Countries visited in last 10 years
YES
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 PROPRITOR
Employer name/business MARZAN DAIRY FARM
Employer Address AMTAIL MOULVIBAZAR
Phone Number
+8801712252643
Past occupation if any BUSINESS PERSON
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 NARAYANA YATHRI RESIDENCY KANYAKUMARI ROAD,KIADB,BOMMASANDRA INDUSTRIAL ARIA BANGALORE KARNATAKA. +919243616388,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e NARAYANA HEALTH FATHEMA BEGUM
Address BOMMASANDRA INDUSTRIAL AREA DOKIN CHOMATKKAR JAGATSHI
ANEKAL TALUK BANGALORE MOULVIBAZAR SADAR MOULVIBAZAR
Phone
08071222222 01726145250
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.

..……………………………………
20-MAY-2019
Date :………………………. Applicant’s signature (as in Passport)