HIGH COMMISSION OF INDIA

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DHAKA(BANGLADESH) recent color photograph.
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Visa Application Form

Signature

BGDDV0B3BB24

A. Personal Particulars (As in Passport)

Surname (As in Passport) KHAN
Application Id : BGDDV0B3BB24

Given Name (As in Passport) MD ASADUZZAMAN

Previous/other Name if any Not Applicable
Gender MALE Marital Status MARRIED
Date of Birth 04-JAN-1985 Religion ISLAM
Place of Birth Town/City DHAKA Country of Birth BANGLADESH
Citizenship /National ID No 6448938875 Educational Qualification GRADUATE
Visible identification marks IN THE LEFT THUMB FINGER HAVE SPOT
Current Nationality Nationality by Birth/
BANGLADESH Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. A06548346 Date of Issue ( dd/mm/yyyy ) 01-FEB-2023
Place of Issue DHAKA Date of Expiry ( dd/mm/yyyy ) 31-JAN-2033
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of Issue Place of Issue
Web Registration Date : 11-JAN-2024

Passport/IC No. Date of issue (dd/mm/yyyy)

Nationality/Status
C. Applicant's Contact Details
Present H/6, SHEIKH ISHADI ROAD Phone No
Address SHAFIPUR, MOUCHAK Mobile /Cell No 8801979448097
GAZIPUR, BANGLADESH 1751 Email address [email protected]

Permanent HAZI MOHOSHIN ROAD

Address HAZINAGAR
DHAKA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
PABNA
Father's MD ABDUS SATTAR KHAN BANGLADESH BANGLADESH
PABNA
Mother's AFROZA KHANOM BANGLADESH BANGLADESH
PABNA
Spouse MARZIA MAZID BANGLADESH BANGLADESH
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

MD ASADUZZAMAN KHAN
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 MEDICAL VISA No of Entries MULTIPLE
Period of Visa ( Month) 12 Month Expected Date of Journey 20-FEB-2024
Port Of Arrival BY AIR Port of Exit BY AIR
Required Detail of MEDICAL VISA
Hospital Name APOLLO GLENEAGLES HOSPITAL KOLKATA
Address KANKURGACHI, KOLKATA, WEST BENGAL 700054
Doctor Name
Phone/Fax +917736037770
Details COLD AND NASAL OBSTRUCTION RECURRENT
Residence Hospital Name MALLEUS ENT SPECIALIZED HOSPITAL LIMITED
Residence Address 24/1 SHAAN TOWER, SHANTINAGAR ROAD, DHAKA-1217
Residence Doctor Name DR BASHUDEB KUMAR SAHA
Residence Phone/Fax +88009613651020
Medical Certificate No
Residence Email
Email

Application Id : BGDDV0B3BB24
Purpose of Visit : FOR PATIENTS
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 CHINA
Have you been refused an Indian Visa or extension of the same previously or deported from India ? NO
G. Profession/Occupation Details :
Present Occupation PRIVATE SERVICE Designation/Rank SENIOR MANAGER
Employer name/business LIDA TEXTILE AND DYEING LIMITED
Employer Address SOFIPUR, KALIAKOIR, GAZIPUR-1751
Phone Number 88029884812
Past occupation if any PRIVATE SERVICE
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 SPOT ON PETALS RESIDENCY HOTEL SATGACHI, KOLKATA, WEST BENGAL 700055 KOLKATA WEST BENGAL.
+911246201612,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Name AMIT BHATT MD MONIRUZZAMAN KHAN
58, CANAL CIRCULAR RD,
Address KADAPARA, PHOOL BAGAN DHAKA, BANAGLADESH
KANKURGACHI, KOLKATA,
WEST BENGAL 700054
KOLKATA WEST BENGAL
Phone Number +917428389979 +8801718443084
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.

11-JAN-2024 ................................
Date : ...................... Applicant's signature (as in Passport)