Shahidur Rahman - Medical

HIGH COMMISSION OF INDIA
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DHAKA(BANGLADESH)
Visa Application Form
Signature
BGDDY39EBF16
A. Personal Particulars (As in Passport)

Surname (As in Passport)
KHA
Given Nam e (As in Passport) SHAHIDUR RAHMAN
Previous/other Name if any
Sex
Web Registration Date : 29-AUG-2016
Application Id :BGDDY39EBF16
Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality
MALE
05-FEB-1972
SATKHIRA
19728719031569422
NIL
BANGLADESH
Marital Status
Religion
Country of Birth
Educational Qualification
MARRIED
ISLAM
BANGLADESH
POST GRADUATE
Nationality by Birth/ Naturalization
BY BIRTH
Date of issue ( dd/mm/yyyy )
06-APR-2015
05-APR-2020
Any Other Previous/Past Nationality

B. Passport Details
BF0076019
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
GONALE
GONALI NALTA, TALA
SATKHIRA, BANGLADESH 9420
Phone No
Mobile /Cell No
01725337685
1725337685
Email address
Permanent GONALE
Address
GONALI NALTA, TALA
SATKHIRA
D. Family Details
Relation
Name
Nationality
Prev. Nationality
Place/Country of Birth
Fathers
MD NOWSAR ALI SHAIKH
BANGLADESH
BANGLADESH
SATKHIRA
BANGLADESH
Mothers
ARFATUNACH
BANGLADESH
BANGLADESH
SATKHIRA
BANGLADESH
Spouse
ASMA PARVIN
BANGLADESH
BANGLADESH
SATKHIRA
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)
MEDICAL VISA
(Month) 12 Month
BY ROAD GHOJADANGA
Type Of Visa Required

Period of Visa
Port Of Arrival
SHAHIDUR RAHMAN KHA
No of Entries
Expected Date of Journey
Port of Exit
MULTIPLE
30-SEP-2016
BY ROAD GHOJADANGA
Required Detail of
MEDICAL VISA
Hospital Name
Address
Doctor Name
Phone/Fax
Details
PEERLESS HOSPITEX HOSPITAL AND RESEARCH CENTER LTD

360, PANCHASAYAR, KOLKATA-700094
DR KOUSTUBH CHAKRABORTY
03324620692
GANGREEN OF RT GREAT TOE
ISLAMI BANK CENTRAL HOSPITAL
KAKRAIL, DHAKA
DR MAHAMUDUL HUQUE
88029360334
Purpose of Visit : MEDICAL TREATEMENT OF SELF

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in MD LIAKAT HOSSAIN
India
Application Id :BGDDY39EBF16
PATHARGHATA , RAJARHAT, NORTH 24 PGS, WB.
Cities in India Visited KOLKATA

Type of Visa TOURIST VISA
Visa Number
VK0625243
Visa Issued Place DHAKA
Date of Issue
15-FEB-2016
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
Present Occupation PRIVATE SERVICE
Designation/Rank
TEACHER
Employer name/business SUVASUNI COLLEGE
Employer Address SUVASUNI, TALA, SATKHIRA
Phone Number
01710409282
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 PATHARGHATA RAJARHAT NORTH 24 PARGANAS WEST BENGAL. 00919775644312,

2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In
ASMA PARVIN
Nam e MD LIAKAT HOSSAIN
Address PATHARGHATA , RAJARHAT
GONALE, GONALI NALTA
NORTH 24 PGS, WB.
Phone
00919775644312
Number
State
Phone No.
BANGLADESH
TALA, SATKHIRA
01919337685
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.
29-AUG-2016
Date :.
..
Applicants signature (as in Passport)

Shahidur Rahman - Medical

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HIGH COMMISSION OF INDIA

Paste your unsigned

Visa Application Form

A. Personal Particulars (As in Passport)

Web Registration Date : 29-AUG-2016

Nationality by Birth/ Naturalization

Date of issue ( dd/mm/yyyy )

Any Other Previous/Past Nationality

Date of expiry (dd/mm/yyyy)

MD NOWSAR ALI SHAIKH

Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

Type Of Visa Required

SHAHIDUR RAHMAN KHA

PEERLESS HOSPITEX HOSPITAL AND RESEARCH CENTER LTD

ISLAMI BANK CENTRAL HOSPITAL

Purpose of Visit : MEDICAL TREATEMENT OF SELF

PATHARGHATA , RAJARHAT, NORTH 24 PGS, WB.

Cities in India Visited KOLKATA

Past occupation if any

1 PATHARGHATA RAJARHAT NORTH 24 PARGANAS WEST BENGAL. 00919775644312,

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