HIGH COMMISSION OF INDIA Paste your unsigned recent color photograph. Size: 2” X 2”
DHAKA(BANGLADESH)
Visa Application Form
Signature
BGDDX169D014
A. Personal Particulars (As in Passport) Surname (As in Passport) SARKER Given Nam e (As in Passport) SABITA Previous/other Name if any
Female 08-OCT-1958 KHULNA 19584719454963896 NIL BANGLADESH
Sex
Application Id :BGDDX169D014
Date of birth Place of Birth Town/City Citizenship /National ID No Visible identification marks Current Nationality
Religion Country of Birth Educational Qualification
Single HINDU BANGLADESH MATRICULATION
Nationality by Birth/ Naturalization
BY BIRTH
Date of issue ( dd/mm/yyyy )
09-OCT-2014 08-OCT-2019
Any Other Previous/Past Nationality B. Passport Details
BC0258769 DHAKA
Passport No. Place of issue
Date of expiry (dd/mm/yyyy)
Any other Passport/Identity Certificate held (if yes ,please fill in the following) YES Country of issue
Web Registration Date : 13-DEC-2014
Marital Status
Passport/IC No Nationality/status
BANGLADESH Y0165220 BANGLADESH
Place of issue Date of issue(dd/mm/yyyy)
KHULNA 17-JAN-2008
C. Applicant’s Contact Details Present address
INDUHATI, PHULTALA, TEROKHADA, KHULNA, BANGLADESH NIL
Phone No
01674968692 Email address
[email protected]
Mobile /Cell No
Permanent INDUHATI, PHULTALA, Address TEROKHADA, KHULNA D. Family Details Relation
Name
Nationality
Prev. Nationality
Place/Country of Birth
Father’s
CHYTHANA SARKAR
BANGLADESH
BANGLADESH
KHULNA BANGLADESH
Mother’s
SUMITRA SAKAR
BANGLADESH
BANGLADESH
KHULNA BANGLADESH
Spouse Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO E. Details of Visa Sought
TOURIST VISA (Month) 12 Month BY AIR/ HARIDASPUR
Type Of Visa Required Period of Visa Port Of Arrival
(Visa shall be valid from the Date of Issue and not from the Date of Journey)
SABITA SARKER
No of Entries Expected Date of Journey Port of Exit
Multiple 30-DEC-2014 BY AIR/ HARIDASPUR
Required Detail of
TOURIST VISA KOLKATA
Purpose of Visit : TOURISM F. Previous Visit Details Have You Ever visited India ? Address where You stayed in India
YES
SUMON SAHA 23, MARQUIS STREET,, KOLKATA,, WEST BENGAL
Cities in India Visited WEST BENGAL Type of Visa TOURIST VISA Visa Number AD492609 Visa Issued Place DHAKA Date of Issue 16-APR-2009 Countries visited in last 10 years NO 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 of Father Present Occupation HOUSE WIFE Designation/Rank HOUSE WIFE Employer name/business CHYTHANA SARKAR Employer Address INDUHATI, PHULTALA, TEROKHADA, 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
1 SUMON SAHA 23, MARQUIS STREET KOLKATA WEST BENGAL . +913322285932, 2 ., 3 ., 4 ., I. Details of Two Reference In India Nam e SUMON SAHA PONCHANON NAG Address 23, MARQUIS STREET INDUHATI, PHULTALA, KOLKATA, WEST BENGAL
Phone +913322285932 Number
In
State
Phone No.
BANGLADESH
TEROKHADA, KHULNA 01674968692
J. DECLARATION: a. b. c. d.
I do not hold any other passport(s) other than those detailed above. I have read and understood all the conditions for the visit to India and I am willing and able to abide fully by them. 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. 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.
13-DEC-2014 Date :……………………….
..…………………………………… Applicant’s signature (as in Passport)
Application Id :BGDDX169D014
Places to be Visited
