HIGH COMMISSION OF INDIA

DHAKA(BANGLADESH) Paste your unsigned

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Visa Application Form

Signature
BGDDV914EE18

A. Personal Particulars (As in Passport)

Appointment Date : 25-MAR-2018 At : 9.00 Hrs.

Surname (As in Passport) ADHIKARY
Given Nam e (As in Passport) TAPASHI
Previous/other Name if any
Sex FEMALE Marital Status MARRIED
Date of birth 10-JUN-1976 Religion HINDU
Application Id :BGDDV914EE18

Place of Birth Town/City KHULNA Country of Birth BANGLADESH

Citizenship /National ID No 19764795123417914 Educational Qualification HIGHER SECONDARY
Visible identification marks NIL
Current Nationality BANGLADESH Nationality by Birth/ Naturalization BY BIRTH
Any Other Previous/Past Nationality
B. Passport Details
Passport No. BC0478959 Date of issue ( dd/mm/yyyy ) 28-OCT-2014
Place of issue DHAKA Date of expiry (dd/mm/yyyy) 27-OCT-2019
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)
Web Registration Date : 18-MAR-2018

Nationality/status

Khulna
C. Applicant’s Contact Details

31, AHSAN AHMED ROAD Phone No 01718003648

Present
address KHULNA SADAR Mobile /Cell No 1909711051
KHULNA, BANGLADESH 9100 Email address

Permanent SUKDARA,SHUKDARA,
Address BATIAGHATA
KHULNA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
KHULNA
Father’s HARAN ADHIKARY BANGLADESH BANGLADESH BANGLADESH
KHULNA
Mother’s KHANAN ADHIKARY BANGLADESH BANGLADESH BANGLADESH
KHULNA
Spouse NANDA ADHIKARY BANGLADESH BANGLADESH 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)

Type Of Visa Required TOURIST VISA No of Entries MULTIPLE

Period of Visa ( Month) 12 Month Expected Date of Journey 31-MAR-2018
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit BY AIR/ HARIDASPUR

TAPASHI ADHIKARY
 Required Detail of TOURIST VISA
Places to be Visited BARASAT, NOWAPARA
N24PGS, WB

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in BARASAT, NOWAPARA
India
N24PGS, WB,

Application Id :BGDDV914EE18
Cities in India Visited KOLKATA
Type of Visa TOURIST VISA Visa Number VK4948243
Visa Issued Place DHAKA Date of Issue 11-JAN-2017
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 Spouse
Present Occupation HOUSE WIFE Designation/Rank HOUSE HOLD WORK
Employer name/business TAPASHI ADHIKARY
Employer Address SUKDARA, SHUKDARA, BATIAGHATA, KHULNA
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 HOTEL DIPLOMAT 10,SADDER STREET KOLKATA WEST BENGAL. 00919830504248,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Nam e RAKESH ADHIKARY GOPAL ADHIKARY
Address BARASAT, NOWAPARA SUKDARA, SHUKDARA
N24PGS, WB BATIAGHATA, KHULNA
Phone
918337020999 01718003648
Number

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.

..……………………………………
18-MAR-2018
Date :………………………. Applicant’s signature (as in Passport)