ASSISTANT HIGH COMMISSION OF INDIA

KHULNA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDKV022C321

A. Personal Particulars (As in Passport)

Surname (As in Passport) MOROL
Given Nam e (As in Passport) MD RABIUL ISLAM
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 17-MAY-1977 Religion ISLAM
Application Id :BGDKV022C321

Place of Birth Town/City KHULNA Country of Birth BANGLADESH

Citizenship /National ID No 8231629471 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. EA0744695 Date of issue ( dd/mm/yyyy ) 21-MAY-2019
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 20-MAY-2024
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-MAR-2021

Nationality/status
C. Applicant’s Contact Details

DEANA SOUTH PARA DEANA MAIN ROAD Phone No 01952140519

Present
address DAULATPUR, DAULATPUR Mobile /Cell No 1952140519
KHULNA, BANGLADESH 9202 Email address

Permanent DEANA SOUTH PARA DEANA MAIN ROAD

Address DAULATPUR, DAULATPUR
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s ABDUL WOHAB MOROL BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s FATEMA BEGUM BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse AFROZA KHATUN 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 08-APR-2021
Port Of Arrival BY ROAD HARIDASPUR Port of Exit BY ROAD HARIDASPUR

MD RABIUL ISLAM MOROL

 Required Detail of MEDICAL VISA
Hospital Name INSTITUTE OF NEUROSCIENCES KOLKATA APOLLO HOSPITALS DHAKA
Address 185/1, A.J.C BOSE ROAD, KOLKATA-700017 PLOT:81, BLOCK: E, BASHUNDHARA R/A, DHAKA-1229
Doctor Name DR SHYAMASHIS DAS DR MD SADIQUL ISLAM
Phone/Fax +913340309999 +88028431661
Details INFLAMMATORY ARTHRITIS

Purpose of Visit : FOR FOREIGN NATIONALS COMING AS MEDICAL ATTENDANTS

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in CAPITAL GUEST HOUSE
India
11-B, CHOWRINGHEE LANE, KOLKATA-700016, WEST BENGAL

Application Id :BGDKV022C321
Cities in India Visited KOLKATA
Type of Visa MEDICAL VISA Visa Number VL2456365
Visa Issued Place DHAKA Date of Issue 29-OCT-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 FARMER Designation/Rank FARMER
Employer name/business MD RABIUL ISLAM MOROL
Employer Address DEANA SOUTH PARA, DAULATPUR, 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 CAPITAL GUEST HOUSE 11-B, CHOWRINGHEE LANE KOLKATA WEST BENGAL. +913322525225,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e CAPITAL GUEST HOUSE AFROZA KHATUN
Address 11-B, CHOWRINGHEE LANE DEANA SOUTH PARA
KOLKATA-700016, WEST BENGAL DAULATPUR, KHULNA
Phone
+913322525225 01952140519
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-MAR-2021
Date :………………………. Applicant’s signature (as in Passport)