Asst High Commission of India Rajshahi

House No-284, Sector-2,Housing Estate

Uposhahar,Rajshahi

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Visa Application Form

Signature

BGDR70040515

Previous/other Name if any

Sex

Web Registration Date : 26-JUL-2015

Application Id :BGDR70040515

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

Male
05-DEC-1974
CHANDPUR
1319585756400
NIL
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

Married
HINDU
BANGLADESH
MATRICULATION

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

23-MAR-2008
22-MAR-2018

Any Other Previous/Past Nationality

B. Passport Details

B1456562
CHANDPUR

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

MUKUL CHANDRA SHEL,SUCHIPARA

SUCHIPARA(NORTH),SHAHRASTI
CHANDPUR, BANGLADESH 3620

Phone No
Mobile /Cell No

01725712377

Email address

Permanent VILL:SUCHIPARA,P.O:SUCHIPARA
Address
P.S:SHAHRASTI
CHANDPUR
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

LATE CHITTORONJON SHEL

BANGLADESH

BANGLADESH

CHANDPUR
BANGLADESH

Mothers

KOLPONA RANI SHEL

BANGLADESH

BANGLADESH

CHANDPUR
BANGLADESH

Spouse

BANGLADESH

BANGLADESH

A
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)

TOURIST VISA
(Month) 12 Month

Type Of Visa Required

Period of Visa
Port Of Arrival

BY RAIL GEDE/BYROAD HARIDASPUR

BABUL CHANDRA SHEL

No of Entries
Expected Date of Journey
Port of Exit

Multiple
31-AUG-2015
BY RAIL GEDE/BYROAD HARIDASPUR

Appointment Date : 05-AUG-2015 At : 12.00

A. Personal Particulars (As in Passport)

Surname (As in Passport)
SHEL
Given Nam e (As in Passport) BABUL CHANDRA

Required Detail of

TOURIST VISA
KOLKATA
WEST BENGAL

Purpose of Visit : TOURISM

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

NO

Cities in India Visited

Type of Visa
Visa Issued Place
Countries visited in last 10 years

Application Id :BGDR70040515

Places to be Visited

Visa Number
Date of Issue

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 PRIVATE SERVICE
Designation/Rank
Employer name/business SREE KRISHNO KANTA SARKER
Employer Address KACHUA MAIN ROAD,MODDOBAZAR,KACHUA,CHANDPUR
Phone Number
01727297980

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 AA AA KOLKATA WEST BENGAL . 11111,

2 .,
3 .,
4 .,
I. Details of Two Reference
In India
Nam e HOTEL SAMRAT
Address 40,SURENDRANATH BENERJEE ROAD,
KOLKATA,WESTBENGAL

Phone
+91 33 22280920
Number

In
SREE REKHA RANI SHEL

State

Phone No.

BANGLADESH

SHAHRASTI,CHANDPUR
01725712377

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.

26-JUL-2015
Date :.

..
Applicants signature (as in Passport)