indian e-token model bgddx82b9516po890921
TRANSCRIPT
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7/26/2019 Indian e-token model BGDDX82B9516PO890921
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Visa Application Form
A. Personal Parti cul ars (As in Passport)
Surname (As in Passport)
Given Name (As in Passport)
Previous/other Name if any
Sex Marital Status
Date of birth Religion
Place of Birth Town/City Country of Birth
Citizenship /National ID No Educational Qualification
Visible identification marks
Current Nationality Nationality by Birth/ Naturalization
Any Other Previous/Past Nationality
B. Passport Details
Passport No. Date of issue ( dd/mm/yyyy )
Place of issue Date of expiry (dd/mm/yyyy)
Any other Passport/Ident it y Cert if icate held (if yes ,p lease fi ll in the fo llowing)
Country of issue Place of issue
Passport/IC No Date of issue(dd/mm/yyyy)
Nationality/status
C. Applicants Contact Details
Phone No
Mobile /Cell NoPresentaddress
Email address
Permanent
Address
D. Family Details
Relation Name Nationalit y Prev. Nationalit y Place/Country of Bir th
Fathers
Mothers
Spouse
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area:
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 No of Entries
Period of Visa Expected Date of Journey
Port Of Arrival Port of Exit
Paste your unsignedrecent color photograph.
Size: 2 X 2
SignatureBGDDX82B9516
POLOK CLEMENT ROZARIO
DHAKA
BANGLADESH
BANGLADESH
BANGLADESH
ApplicationId:BGDDX82B9516
GAZIPUR
POLOK CLEMENT
BANGLADESH
WebR
egistrationDate:10-J
UN-2
016
BY ROAD CHANGRABANDHA/JAYGAON
18-AUG-2014
17-AUG-2019
6 Month
ROZARIO
DHAKA(BANGLADESH)
BY BIRTH
N/A
GAZIPUR
GAZIPUR
BANGLADESH
BY ROAD CHANGRABANDHA/JAYGAON
DARIPARA, KALIGANJ,
KALIGANJGAZIPUR
21-SEP-1989
BANGLADESH
Multiple
KOMAL CLEMENT ROZARIO
Male
19892698879312005
BANGLADESH
BB0837306
Single
NO
01720046697
NO
(Month)
PUSHPA TERESA ROZARIO
HIGH COMMISSION OF INDIA
05-JUL-2016
TOURIST VISA
BANGLADESH
POST GRADUATE
SYTRAPUR
CHRISTIAN
18 SHERIS DAS LANE
DHAKA, BANGLADESH 1100
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Required Detail of
Purpose of Visit :
F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed inIndia
Cities in India Visited
Type of Visa Visa Number
Visa Issued Place Date of Issue
Countries visited in last 10 years
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 controlNo/Date
G. Profession/Occupation DetailsPresent Occupation Designation/Rank
Employer name/businessEmployer AddressPhone Number
Past occupation if any
Are/have you worked with Armed forces/ Police/ Para Military forces ?
Organization Designation
Place of Posting Rank
H. Address of Place of Stay / Hotel
Place/Hotel Name Address of Place / Hotel State Phone No.
I. Details of Two Reference
In India In
Name
Address
PhoneNumber
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.
..Date :. Applicants signature (as in Passport)
4 . ,
PUSHPA TERESA ROZARIO
NO
3 . ,
Ap
plicationId:BGDDX82B9516
CARITAS DEVELOPMENT INSTITUTE
PRIVATE SERVICE
18 SHRISH DAS LANE,
2 . ,
10-JUN-2016
01715733315
VOLUNTEER
WEST BENGAL, KOLKATA
1 HOTEL ROYAL GARDEN 163/A, PARK STREET KOLKATA WEST BENGAL . +919831600215,
2, OUTER CIRCULAR ROAD, SHANTIBAGH, DHAKA-1217
163/A, PARK STREET,
DHAKA-1100
,
HOTEL ROYAL GARDEN
+9198316900215
Places to be Visited
9339625
NO
TOURISM
WEST BENGAL KOLKATA
TOURIST VISA