HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

recent color photograph.
Size: 2” X 2”

Visa Application Form

Signature
BGDDV4A6EC20

A. Personal Particulars (As in Passport)

Surname (As in Passport) RAHMAN
Given Nam e (As in Passport) ZILLUR
Previous/other Name if any
Sex MALE Marital Status MARRIED
Date of birth 28-DEC-1985 Religion ISLAM
Application Id :BGDDV4A6EC20

Place of Birth Town/City CHANDPUR Country of Birth BANGLADESH

Citizenship /National ID No 6423376893 Educational Qualification GRADUATE
Visible identification marks NILL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BP0364728 Date of issue ( dd/mm/yyyy ) 04-JUN-2017
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 03-JUN-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 : 26-DEC-2020

Nationality/status
C. Applicant’s Contact Details

39, ROAD -6/A Phone No

Present
address DHANMONDI Mobile /Cell No 1712290420
DHAKA, BANGLADESH 1209 Email address

Permanent DIGDHAIR, MANTALA

Address FARIDGANJ
CHANDPUR

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
CHANDPUR
Father’s M A MOMIN BANGLADESH BANGLADESH BANGLADESH
CHANDPUR
Mother’s REHANA BEGUM BANGLADESH BANGLADESH BANGLADESH
CHANDPUR
Spouse MOSTARINA SHARMIN 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 BUSINESS VISA No of Entries MULTIPLE

Period of Visa ( Month) 36 Month Expected Date of Journey 10-JAN-2021
Port Of Arrival BY AIR Port of Exit BY AIR

ZILLUR RAHMAN
 Required Detail of BUSINESS VISA
Company Name BRN COMMODITIES AND TRADING CO PVT LTD
Address 3A MANGOE LANE,GROUND FLOOR,KOLKATA 700001
Phone 03340673062
Email

Purpose of Visit : FOR ALL OTHER BUSINESS ACTIVITIES (OTHER THAN THOSE COVERED UNDER B-1 AND SPORTS PERSONS
F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in KOLKATA
India
,

Application Id :BGDDV4A6EC20
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VL5361780
Visa Issued Place DHAKA Date of Issue 20-JAN-2020
Countries visited in last 10 years
INDIA,KSA
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 DIRECTOR PLANNING AND DEVELOPMENT
Employer name/business BEYOND TRADE INTERNATIONAL
Employer Address 106, NORTH DHANMONDI,KALABAGAN DHAKA 1205
Phone Number
01712290420
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 PARADISE HOTEL 03, NO. C,, 75, PARK ST, KOLKATA KOLKATA WEST BENGAL. +91 83486 22100,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e STAR GUEST HOUSE MD YEASIR ARAFAT
Address 44 RABINDRA SARANI 39,ROAD-6/A
KOLKATA DHANMONDI DHAKA
Phone
9885623546 01716668516
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.

..……………………………………
26-DEC-2020
Date :………………………. Applicant’s signature (as in Passport)