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****

HIGH COMMISSION OF INDIA

Paste your unsigned
recent color photograph.
Size: 2 X 2

DHAKA(BANGLADESH)
BOTH PHOTO'S SHOULD
BE SAME

Visa Application Form

SURNAME SHOULD BE
SAME AS IN PASSPORT
NAME SHOULD BE
SAME AS IN PASSPORT

BGDDV1895616

Signature

A. Personal Particulars (As in Passport)

Surname (As in Passport)

HOSSAIN

Given Nam e (As in Passport)

MAHMUD

MUST BE SAME AS IN
PASSPORT

SIGNATURE AS SAME
AS IN PASSPORT

Previous/other Name if any

Sex

Marital Status
Religion
Country of Birth
Educational Qualification

Male

Date of birth

01-JAN-1975

Place of Birth Town/City

DHAKA

Citizenship /National ID No

197512345678111

Visible identification marks

NA

Current Nationality

BANGLADESH

Any Other Previous/Past Nationality

BANGLADESH

AS IN
PASSPORT

GRADUATE

Nationality by Birth/ Naturalization BY BIRTH

XX123458

Place of issue

ISLAM

GIVE YOUR CURRENT VALID

PASSPORT NO

B. Passport Details
Passport No.

Married

DHAKA

Date of issue ( dd/mm/yyyy )

03-JAN-2016

Date of expiry (dd/mm/yyyy)

02-JAN-2020

NO

Any other Passport/Identity Certificate held (if yes ,please fill in the following)
Country of issue
Place of issue
Passport/IC No

Date of issue(dd/mm/yyyy)

Nationality/status
C. Applicants Contact Details

A-1,B-2
Present
address

BB-----

MUST BE SAME
AS IN UTILITY
BILL ADDRESS

Phone No
Mobile /Cell No

017111111111

Email address yyy@mail.com

DHAKA, BANGLADESH 1200

Permanent A-1,B-2
Address
BB-----

GIVE YOUR
VALID PHONE
NUMBER & EMAIL

DHAKA

D. Family Details
Relation

Name

Fathers

MD XYZ

BANGLADESH

BANGLADESH

MRS XYZ

BANGLADESH

BANGLADESH

XYZ

BANGLADESH

BANGLADESH

Mothers

Spouse

Nationality

Prev. Nationality

Place/Country of Birth
DHAKA
BANGLADESH
DHAKA
BANGLADESH
DHAKA
BANGLADESH

SHOULD NOT
BE LEFT BLANK

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
Type Of Visa Required No of Entries
Period of Visa
Port Of Arrival

(Month) 126Month
MONTH

BY AIR/ HARIDASPUR

PORT
PORTSHOULD
SHOULDBE
BE
SPECIFIED
SAME
Expected Date of Journey
Port of Exit

Multiple
25-JAN-2016
BY AIR/ HARIDASPUR

TOURIST VISA
Required Detail of

Purpose of Visit : TOURISM

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

India

SHOULD NOT BE
LEFT BLANK
YES

GIVE YOUR PREVIOUS

VISA NUMBER &
ISSUE DATE.

AA
BB, CC

Cities in India Visited A

Type of Visa TOURIST VISA
Visa Issued Place DHAKA
Countries visited in last 10 years

Visa Number
Date of Issue

VN12345156
01-JAN-2015

THAILAND,UK,MALAYSIA

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
Employer name/business

PRIVATE SERVICE

Designation/Rank

XYZ

Employer Address A B C 123

Phone Number 017111111111111
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 XYZ 9 MA ABC XYZ KOLKATA WEST BENGAL . 0091100000000,

PLEASE GIVE
GENUINE CONTACT
DETAILS

2
.,
3
.,
4
.,
I. Details of Two Reference

In India In

MD XYZ

BANGLADESH
MD ABC

Name
Address

ROAD NO-111,FLAT-A,ABC LANE,

A B C D ...... DHAKA

KOLKATA

BANGLADESH

Phone +91000000000000

Number

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 :. SIGNATURE MUST BE SAME

AS IN PASSPORT

Applicants signature (as in Passport)

Application Id :BGDDV1895616

Places to be Visited