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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDW8D66E15

A. Personal Particulars (As in Passport)

Surname (As in Passport)
ADRIN
Given Nam e (As in Passport) AZWAD TASNIM
Previous/other Name if any

Web Registration Date : 12-MAY-2015

Application Id :BGDDW8D66E15

Sex
Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality

Female
08-DEC-2007
DHAKA
20073091001025780
NA
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

Single
ISLAM
BANGLADESH
BELOW MATRICULATION

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

30-MAY-2012
29-MAY-2017

Any Other Previous/Past Nationality

B. Passport Details

AC2805388
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) NO
Country of issue

Place of issue

Passport/IC No

Date of issue(dd/mm/yyyy)

Nationality/status
C. Applicants Contact Details
Present
address

HOUSE:18, ROAD:3/B, SECTOR:09

UTTARA
DHAKA, BANGLADESH 1230

Phone No

01711242181
Email address mazad_71@yahoo.com

Mobile /Cell No

Permanent HOUSE:18, ROAD:3/B, SECTOR:09

Address
UTTARA
DHAKA
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

MOHAMMAD AZAD RAHMAN

BANGLADESH

BANGLADESH

DHAKA
BANGLADESH

Mothers

REHANA PARVEEN

BANGLADESH

BANGLADESH

JESSORE
BANGLADESH

Spouse
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)

MEDICAL ATTENDANT
(Month) 12 Month
BY AIR/ HARIDASPUR

Type Of Visa Required

Period of Visa
Port Of Arrival

AZWAD TASNIM ADRIN

No of Entries
Expected Date of Journey
Port of Exit

Multiple
15-MAY-2015
BY AIR/ HARIDASPUR

Required Detail of

MEDICAL ATTENDANT

Patient Name
Patient Passport No.
Relation With Patient

AFZAL HOSSAIN
AD4885585
GRAND FATHER

Purpose of Visit : ACCOMPANYING PATIENT

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in SILVER SPRING
India

Application Id :BGDDW8D66E15

BLOCK:1, FLAT:6A, BYPASS, KOLKATA,

Cities in India Visited KOLKATA

Type of Visa TOURIST VISA
Visa Number
VI4046756
Visa Issued Place DHAKA
Date of Issue
21-AUG-2012
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 of Father
Present Occupation STUDENT
Designation/Rank
Employer name/business MOHAMMAD AZAD AHMANR
Employer Address HOUSE:18, ROAD:3/B, SECTOR:09, UTTARA, DHAKA
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 SILVER SPRING BLOCK:1, FLAT:6A, BYPASS KOLKATA WEST BENGAL . 9830043166, atdas@vsnl.co.in
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In BANGLADESH
Nam e AMIT KUMAR DAS
MOHAMMAD AZAD RAHMAN
Address 363 DASKHINDARI, LAHA BAGAN
HOUSE:18, ROAD:3/B, SECTOR:9
KOLKATA 7400 048

Phone
9830043166
Number

UTTARA, DHAKA, BANGLADESH

01713001958

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.

12-MAY-2015
Date :.

..
Applicants signature (as in Passport)