BGDCV324F222MD820101

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ASSISTANT HIGH COMMISSION OF INDIA

CHITTAGONG(BANGLADESH) Paste your unsigned


recent color photograph.
Size: 2" X 2"

Visa Application Form

Signature
BGDCV324F222

A. Personal Particulars (As in Passport)


Surname (As in Passport) HOSSAIN
Application Id : BGDCV324F222

Given Name (As in Passport) MD AKBOR


Previous/other Name if any Not Applicable
Gender MALE Marital Status MARRIED
Date of Birth 01-JAN-1982 Religion ISLAM
Place of Birth Town/City CUMILLA Country of Birth BANGLADESH
Citizenship /National ID No 3262001112 Educational Qualification HIGHER SECONDARY
Visible identification marks NA
Current Nationality Nationality by Birth/
BANGLADESH Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. A01113731 Date of Issue ( dd/mm/yyyy ) 21-JUN-2021
Place of Issue DHAKA Date of Expiry ( dd/mm/yyyy ) 20-JUN-2031
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Web Registration Date : 07-NOV-2022

Country of Issue Place of Issue


Passport/IC No. Date of issue (dd/mm/yyyy)
Nationality/Status
C. Applicant's Contact Details
SHABNAGAR, KOTWALI
Present MODEL, Phone No 01612011045
Address COMILLA, COMILLA-3501 Mobile /Cell No 8801612011045
CUMILLA, BANGLADESH 3501 Email address VISSA.INFO@GMAIL.COM

SHABNAGAR, KOTWALI
Permanent MODEL,
CUMILLA CANTOMENT-
Address 3501,CUMILLA
CUMILLA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
CUMILLA
Father's MD SHAMSUL HOQUE BANGLADESH BANGLADESH BANGLADESH
CUMILLA
Mother's MST FIROZA AKTER BANGLADESH BANGLADESH BANGLADESH
CUMILLA
Spouse SUMAIYA AKTER BANGLADESH BANGLADESH BANGLADESH
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

MD AKBOR HOSSAIN
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 TOURIST VISA No of Entries MULTIPLE
Period of Visa ( Month) 12 Month Expected Date of Journey 30-NOV-2022
Port Of Arrival BY ROAD SRIMANTPUR Port of Exit BY ROAD SRIMANTPUR
Required Detail of TOURIST VISA
Places to be Visited KOLKATA,DELHI,AGARTALA

Purpose of Visit : TOURISM,RECREATION,SIGHT-SEEING


F. Previous Visit Details
Have You Ever visited India ? NO
Address where You stayed in
India ,
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10
years
Have you been refused an Indian Visa or extension of the same previously or deported

Application Id : BGDCV324F222
from India ? NO
G. Profession/Occupation Details :
Present Occupation BUSINESS PERSON Designation/Rank OWNER
Employer name/business SECURE CYBER CAFE
311, CHANDPUR BABY STAND,GANGCHAR,CUMILLA
Employer Address SADAR
Phone Number 01612011045
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 HOTEL POLO TOWERS AGARTALA VIP ROAD, KRISHNA NAGAR NORTH TRIPURA TRIPURA. +91 381231 0110,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
HOTEL POLO TOWERS
Name AGARTALA SUMAIYA AKTER
Address VIP ROAD, KRISHNA NAGAR SHABNAGAR, KOTWALI MODEL,
WEST TRIPURA TRIPURA CUMILLA CANTONMENT-3501,CUMILLA
Phone Number +913812310110 01612011045
K. 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.
e. I will also submit hard-copy all the uploaded documents along with the print of application to submit to the concerning Indian
Mission or Agency for processing of visa application.

07-NOV-2022 ................................
Date : ...................... Applicant's signature (as in Passport)

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