ASSISTANT HIGH COMMISSION OF INDIA

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SYLHET(BANGLADESH) recent color photograph.
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Visa Application Form

Signature

BGDSV1B70B24

A. Personal Particulars (As in Passport)

Surname (As in Passport) ROY
Application Id : BGDSV1B70B24

Given Name (As in Passport) LIPI RANI

Previous/other Name if any Not Applicable
Gender FEMALE Marital Status MARRIED
Date of Birth 20-AUG-1985 Religion HINDU
Place of Birth Town/City SUNAMGANJ Country of Birth BANGLADESH
Citizenship /National ID No 9013223413931 Educational Qualification MATRICULATION
Visible identification marks NILL
Current Nationality Nationality by Birth/
BANGLADESH Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. A16053491 Date of Issue ( dd/mm/yyyy ) 09-SEP-2024
Place of Issue DHAKA Date of Expiry ( dd/mm/yyyy ) 08-SEP-2029
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Web Registration Date : 19-NOV-2024

Country of Issue Place of Issue

Passport/IC No. Date of issue (dd/mm/yyyy)
Nationality/Status
C. Applicant's Contact Details
Present ELECTRIC Phone No 01727190473
Address SUPPLY ROAD Mobile /Cell No 8801727190473
SYLHET, BANGLADESH 3100 Email address [email protected]

Permanent KAYETKANDA, MADHANAGAR

Address MADDHONAGAR
SUNAMGANJ

D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
SUNAMGANJ
Father's RANODHIR SAHA BANGLADESH BANGLADESH BANGLADESH
SUNAMGNAJ
Mother's ANJANA RANI SAHA BANGLADESH BANGLADESH BANGLADESH
SUNAMGNAJ
Spouse SAILEN ROY BANGLADESH BANGLADESH BANGLADESH
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO

LIPI RANI ROY

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) 6 Month Expected Date of Journey 20-DEC-2024
Port Of Arrival BY ROAD DAWKI Port of Exit BY ROAD DAWKI
Required Detail of MEDICAL VISA
Hospital Name CHRISTIAN MEDICAL COLLEGE
Address IDA SCUDDER RD, VELLORE, TAMIL NADU 632004, INDIA
Doctor Name DR. NICHOLAS VIJAY RAO G
Phone/Fax
Details GASTROENTEROLOGY CLINIC RANIPET
Residence Hospital Name SODESH HOSPITAL (PVT) LIMITED
Residence Address 298/2 MASKANDA, MYMENSINGH
Residence Doctor Name DR GAZI ABUL HOSSAIN
Residence Phone/Fax
Medical Certificate No
Residence Email
Email

Application Id : BGDSV1B70B24
Purpose of Visit : FOR FOREIGN NATIONALS COMING AS MEDICAL ATTENDANTS
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
Have you been refused an Indian Visa or extension of the same previously or deported from India ? NO
G. Profession/Occupation Details : of Spouse
Present Occupation HOUSE WIFE Designation/Rank PROPRIETOR
Employer name/business VAI BON PAN SUPARI
Employer Address
Phone Number MADDHONAGAR BAZAR, MADDHONAGAR, SUNAMGANJ
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 SKB HOTEL GRAND DAYS 31/13,THIRUVENGADAM ST,PERIYAMET CHENNAI TAMIL NADU. 914442811925,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Name SKB HOTEL GRAND DAYS SAILEN ROY
31/13,THIRUVENGADAM
Address ST,PERIYAMET KAYETKANDA,MADHANAGAR
CHENNAI TAMIL NADU MADDHONAGAR, SUNAMGANJ
Phone Number 914442811925 01727190473
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.

19-NOV-2024 ................................
Date : ...................... Applicant's signature (as in Passport)