HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDDX6553917

A. Personal Particulars (As in Passport)

Surname (As in Passport) BULBUL
Given Nam e (As in Passport) QURBAN ALI
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 20-JUL-1986 Religion ISLAM
DHAKA BANGLADESH
Application Id :BGDDX6553917

Place of Birth Town/City Country of Birth

Citizenship /National ID No 2613451251278 Educational Qualification HIGHER SECONDARY
Visible identification marks RIGHT EYE IS WHITE
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BJ0919124 Date of issue ( dd/mm/yyyy ) 14-JAN-2016
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 13-JAN-2021
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 : 17-OCT-2017

Nationality/status
C. Applicant’s Contact Details

H-36, R-05, W-57 Phone No

Present
address MIDDLE ISLAM NAGAR Mobile /Cell No 1913614182
DHAKA, BANGLADESH 1211 Email address QURBAANALIBULBUL@GMAIL.COM

Permanent H-36, R-05, W-57

Address MIDDLE ISLAM NAGAR
DHAKA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
MUNSHIGANJ
Father’s ABDUL JALIL KHAN BANGLADESH BANGLADESH BANGLADESH
MUNSHIGANJ
Mother’s ALEYA BEGUM BANGLADESH BANGLADESH BANGLADESH
DHAKA
Spouse MAFRUHA KHAN 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-OCT-2017
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit BY AIR/ HARIDASPUR

QURBAN ALI BULBUL

 Required Detail of TOURIST VISA
Places to be Visited KOLKATA

Purpose of Visit : MEETING FRIENDS/RELATIVES

F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India
,

Application Id :BGDDX6553917
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years
KINGDOM OF SAUDI ARABIA
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 IT OFFICER
Employer name/business H M AIR TRAVELS
Employer Address 72 / BEGUM BAZAR / CHAWK BAZAR / DHAKA
Phone Number
02 57313771
Past occupation if any PRIVATE SERVICE
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 SAMRAT 23 MARQUIS STREET KOLKATA WEST BENGAL. 008801913614182, QURBAANALIBULBUL@GMAIL.COM
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e HOTEL SAMRAT ABDUR RAZZAQUE
Address 23, MARQUIS STREET, 36 MIDDLE ISLAM NAGAR, ASHRAFABAD,
KOLKATA-16, WEST BENGAL INDIA KAMRANGIRCHAR, DHAKA-1211
Phone
22520190 01952774799
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.

..……………………………………
17-OCT-2017
Date :………………………. Applicant’s signature (as in Passport)