HIGH COMMISSION OF INDIA

Paste your unsigned

DHAKA(BANGLADESH) recent color photograph.
Size: 2" X 2"

Visa Application Form

Signature

BGDDW2E6E024

A. Personal Particulars (As in Passport)

Surname (As in Passport) UDDIN
Application Id : BGDDW2E6E024

Given Name (As in Passport) MD HELAL

Previous/other Name if any Not Applicable
Gender MALE Marital Status MARRIED
Date of Birth 01-JAN-1983 Religion ISLAM

Biometric Enrollment is not required till 12/JUL/2028.

Place of Birth Town/City DHAKA Country of Birth BANGLADESH
Citizenship /National ID No 3287541084 Educational Qualification GRADUATE
Visible identification marks NIL
Current Nationality Nationality by Birth/
BANGLADESH Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. A10960008 Date of Issue ( dd/mm/yyyy ) 13-JUN-2023
Place of Issue DHAKA Date of Expiry ( dd/mm/yyyy ) 12-JUN-2033
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Country of Issue Place of Issue
Web Registration Date : 02-DEC-2024

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

Nationality/Status
C. Applicant's Contact Details
Present NATUN PARA Phone No 01715628292
Address DENDABAR Mobile /Cell No 8801715628292
DHAKA, BANGLADESH 1344 Email address SHUVO2ORSHI@[Link]

Permanent NATUN PARA

Address DENDABAR
DHAKA

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
DHAKA
Father's ABDUL HAKIM BANGLADESH BANGLADESH
DHAKA
Mother's HAZERA KHATUN BANGLADESH BANGLADESH
DHAKA
Spouse NAHIDA SULTANA LIPI BANGLADESH BANGLADESH
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

MD HELAL UDDIN
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-JUN-2025
Port Of Arrival BY AIR/ HARIDASPUR Port of Exit BY AIR/ HARIDASPUR
Required Detail of MEDICAL VISA
Hospital Name CK BIRLA HOSPITAL
Address KOLKATA, INDIA
Doctor Name
Phone/Fax
Details CARDIOVASCULAR
Residence Hospital Name NATIONAL INSTITUTE OF CARDIOVASCULAR DISEASES
Residence Address SHER-E-BANGLA NAGAR, DHAKA
Residence Doctor Name
Residence Phone/Fax
Medical Certificate No
Residence Email
Email

Application Id : BGDDW2E6E024
Purpose of Visit : FOR PATIENTS
F. Previous Visit Details
Have You Ever visited India ? YES
Address where You stayed in AIRPORT PLAZA HOTEL 14, NEAR AIRPOR
India ,
Cities in India Visited KOLKATA, DELHI, MUMBAI
Type of Visa TOURIST VISA Visa Number VN1047318
Visa Issued Place DHAKA Date of Issue 28-MAR-2024
Countries visited in last 10 years
Have you been refused an Indian Visa or extension of the same previously or deported from India ? NO
G. Profession/Occupation Details :
Present Occupation BUSINESS PERSON Designation/Rank PROPRIETOR
Employer name/business HELAL ENTERPRISE
Employer Address DENDABAR, SAVAR CANTONMENT, ASHULIA, SAVAR, DHAKA
Phone Number 01715628292
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 AIRPORT PLAZA HOTEL 14, NEAR AIRPORT GATE NO 1 KOLKATA KOLKATA WEST BENGAL. 03340111222,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Name AIRPORT PLAZA HOTEL MD ALAUDDIN
14, NEAR AIRPORT GATE NO
Address 1 KOLKATA DENDABORE NATUN PARA
KOLKATA WEST BENGAL SAVAR CANTT, ASHULIA DHAKA
Phone Number 03340111222 01716816747
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.

02-DEC-2024 ................................
Date : ...................... Applicant's signature (as in Passport)
Biometric Enrollment is not required till 12/JUL/2028.