HIGH COMMISSION OF INDIA

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DHAKA(BANGLADESH)

Visa Application Form

Signature

BGDDX82B9516

A. Personal Particulars (As in Passport)

Surname (As in Passport)
ROZARIO
Given Nam e (As in Passport) POLOK CLEMENT
Previous/other Name if any
Sex

Web Registration Date : 10-JUN-2016

Application Id :BGDDX82B9516

Date of birth
Place of Birth Town/City
Citizenship /National ID No
Visible identification marks
Current Nationality

Male
21-SEP-1989
GAZIPUR
19892698879312005
N/A
BANGLADESH

Marital Status
Religion
Country of Birth
Educational Qualification

Single
CHRISTIAN
BANGLADESH
POST GRADUATE

Nationality by Birth/ Naturalization

BY BIRTH

Date of issue ( dd/mm/yyyy )

18-AUG-2014
17-AUG-2019

Any Other Previous/Past Nationality

B. Passport Details

BB0837306
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

18 SHERIS DAS LANE

SYTRAPUR
DHAKA, BANGLADESH 1100

Phone No

01720046697

Mobile /Cell No
Email address clement_rozario@hotmail.com

Permanent DARIPARA, KALIGANJ,

Address
KALIGANJ
GAZIPUR
D. Family Details
Relation

Name

Nationality

Prev. Nationality

Place/Country of Birth

Fathers

KOMAL CLEMENT ROZARIO

BANGLADESH

BANGLADESH

GAZIPUR
BANGLADESH

Mothers

PUSHPA TERESA ROZARIO

BANGLADESH

BANGLADESH

GAZIPUR
BANGLADESH

Spouse
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)

TOURIST VISA
(Month) 6 Month

Type Of Visa Required

Period of Visa
Port Of Arrival

BY ROAD CHANGRABANDHA/JAYGAON

POLOK CLEMENT ROZARIO

No of Entries
Expected Date of Journey
Port of Exit

Multiple
05-JUL-2016
BY ROAD CHANGRABANDHA/JAYGAON

Required Detail of

TOURIST VISA
WEST BENGAL KOLKATA

Purpose of Visit : TOURISM

F. Previous Visit Details
Have You Ever visited India ?
Address where You stayed in
India

NO

Cities in India Visited

Type of Visa
Visa Issued Place
Countries visited in last 10 years

Visa Number
Date of Issue

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
VOLUNTEER
Employer name/business CARITAS DEVELOPMENT INSTITUTE
Employer Address 2, OUTER CIRCULAR ROAD, SHANTIBAGH, DHAKA-1217
Phone Number
9339625

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 HOTEL ROYAL GARDEN 163/A, PARK STREET KOLKATA WEST BENGAL . +919831600215,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India
In
Nam e HOTEL ROYAL GARDEN
PUSHPA TERESA ROZARIO
Address 163/A, PARK STREET,
18 SHRISH DAS LANE,
WEST BENGAL, KOLKATA

Phone
+9198316900215
Number

State

Phone No.

BANGLADESH

DHAKA-1100
01715733315

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.

10-JUN-2016
Date :.

..
Applicants signature (as in Passport)

Application Id :BGDDX82B9516

Places to be Visited