Visa Application Form - ivacbd.com

1 BGDDV1895616 HIGH COMMISSION OF INDIA DHAKA(BANGLADESH) visa Application form Signature Paste your unsigned recent color photograph. Size: 2 X 2 A. Personal Particulars (As in Passport) Surname (As in Passport) Given Name (As in Passport) Previous/other Name if any Sex Date of birth Place of Birth Town/City Citizenship /National ID No Visible identification marks HOSSAIN MAHMUD Male 01-JAN-1975 DHAKA 197512345678111 NA Marital Status Religion Country of Birth Educational Qualification Married ISLAM BANGLADESH GRADUATE Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH Any Other Previous/Past Nationality B. Passport Details Passport No. Place of issue XX123458 DHAKA Date of issue ( dd/mm/yyyy ) Date of expiry (dd/mm/yyyy) 03-JAN-2016 02-JAN-2020 Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO Country of issue Passport/IC No Nationality/status C.

2 Applicant s Contact Details A-1,B-2 Place of issue Date of issue(dd/mm/yyyy) Phone No Present address BB----- DHAKA, BANGLADESH 1200 Mobile /Cell No 017111111111 Email address Permanent A-1,B-2 Address BB----- DHAKA D. Family Details Relation Name Nationality Prev. Nationality Place/Country of Birth Father s Mother s Spouse MD XYZ MRS XYZ XYZ BANGLADESH BANGLADESH BANGLADESH BANGLADESH BANGLADESH BANGLADESH DHAKA BANGLADESH DHAKA BANGLADESH DHAKA BANGLADESH Were your Grandfather/Grandmother(Paternal/Materna l) 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) TOURIST visa Multiple Type Of visa Required No of Entries Period of visa (Month)

3 Port Of Arrival 12 Month BY AIR/ HARIDASPUR Expected Date of Journey Port of Exit 25-JAN-2016 BY AIR/ HARIDASPUR SURNAME SHOULD BE SAME AS IN PASSPORTMUST BE SAME AS IN PASSPORTGIVE YOUR CURRENT VALID PASSPORT NOMUST BE SAME AS IN UTILITY BILL ADDRESSGIVE YOUR VALID PHONE NUMBER & EMAIL SHOULD NOT BE LEFT BLANKNAME SHOULD BE SAME AS IN PASSPORTPORT SHOULD BE SAMEBOTH PHOTO'S SHOULD BE SAMEAS IN PASSPORTSIGNATURE AS SAME AS IN PASSPORT 6 MONTH Required Detail of Places to be Visited TOURIST visa K Purpose of Visit : TOURISM F. Previous Visit Details Have You Ever visited India ? Address where You stayed in India YES AA BB, CC Cities in India Visited A Type of visa TOURIST visa visa Issued Place DHAKA Countries visited in last 10 years THAILAND,UK,MALAYSIA visa Number Date of Issue VN12345156 01-JAN-2015 Have you been refused an Indian visa or extension of the same previously or deported from India ?

4 If yes above mention when and by whom with control No/Date G. Profession/Occupation Details Present Occupation PRIVATE SERVICE Designation/Rank Employer name/business XYZ Employer Address A B C 123 A Phone Number Past occupation if any 017111111111111 Are/have you worked with Armed forces/ Police/ Para Military forces ? NO Organization Place of Posting H. Address of Place of Stay / Hotel Place/Hotel Name Address of Place / Hotel 1 HOTEL XYZ 9 MA ABC XYZ KOLKATA WEST BENGAL . 0091100000000, 2 . , 3 . , 4 . , I. Details of Two Reference Designation Rank State Phone No. MD XYZ In India In BANGLADESH MD ABC Name Address ROAD NO-111,FLAT-A,ABC LANE, KOLKATA A B C D.

5 DHAKA BANGLADESH Phone Number +91000000000000 017000000000 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.. 12-JAN-2016 Date.

6 Applicant s signature (as in Passport) 6 Application Id :BGDDV1895616 GIVE YOUR PREVIOUS visa NUMBER & ISSUE MUST BE SAME AS IN PASSPORTPLEASE GIVE GENUINE CONTACT DETAILSSHOULD NOT BE LEFT BLANK