HIGH COMMISSION OF INDIA
Paste your unsigned
DHAKA(BANGLADESH) recent color photograph.
Size: 2" X 2"
Visa Application Form
Signature
BGDDV2073725
A. Personal Particulars (As in Passport)
Surname (As in Passport) TABASSUM
Application Id : BGDDV2073725
Given Name (As in Passport) RAWSHAN
Previous/other Name if any Not Applicable
Gender FEMALE Marital Status SINGLE
Date of Birth 07-NOV-2004 Religion ISLAM
Place of Birth Town/City MYMENSINGH Country of Birth BANGLADESH
Citizenship /National ID No 20046125515280502 Educational Qualification HIGHER SECONDARY
Visible identification marks MOLE AT RIGHT HAND ELBOW
Current Nationality Nationality by Birth/
BANGLADESH Naturalization BY BIRTH
Any Other Previous/Past Nationality Not Applicable
B. Passport Details
Passport No. B00308446 Date of Issue ( dd/mm/yyyy ) 26-SEP-2022
Place of Issue DHAKA Date of Expiry ( dd/mm/yyyy ) 25-SEP-2027
Any other Passport/Identity Certificate held (if yes ,please fill in the following) NO
Web Registration Date : 09-MAR-2025
Country of Issue Place of Issue
Passport/IC No. Date of issue (dd/mm/yyyy)
Nationality/Status
C. Applicant's Contact Details
NAVANA GLORIOSA,79,INDIRA
Present ROAD Phone No 01778689448
Address DHAKA Mobile /Cell No 88001778689448
DHAKA, BANGLADESH 1206 Email address
[email protected] Permanent 306/27/1 AMERABAD
Address SADAR
MYMENSINGH
D. Family Details
Relation Name Nationality Prev. Nationality Place/Country of Birth
MYMENSINGH
Father's LIAQUAT ALI KHAN BANGLADESH BANGLADESH BANGLADESH
MYMENSINGH
Mother's NASRIN KHANUM BANGLADESH BANGLADESH BANGLADESH
Marital Status Single
Were your Grandfather/Grandmother(Paternal/Maternal) Pakistan Nationals Or belong to Pakistan held area : NO
RAWSHAN TABASSUM
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 SINGLE
Period of Visa ( Month) 1 Month Expected Date of Journey 14-MAR-2025
Port Of Arrival BY AIR Port of Exit BY AIR
Required Detail of MEDICAL VISA
Hospital Name SITARAM BHARTIA
Address B-16, QUTAB INSTITUTIONAL AREA, NEW DELHI
Doctor Name DR. VIKRAM ARUN MHASKAR
Phone/Fax 911142111111
Details COMPLETE TEAR OF ACL
Residence Hospital Name LABAID SPECIALIZED HOSPITAL
Residence Address HOUSE-06, ROAD-04, DHANMONDI, DHAKA
Residence Doctor Name DR. M. AMJAD HOSSAIN
Residence Phone/Fax 8802 586107938
Medical Certificate No
Residence Email [email protected]
Email [email protected]
Application Id : BGDDV2073725
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
Have you been refused an Indian Visa or extension of the same previously or deported from India ? NO
G. Profession/Occupation Details :
Present Occupation STUDENT Designation/Rank NA
Employer name/business HOMEMAKER
Employer Address 79,INDIRA ROAD,FARMGATE,DHAKA, BANGLADESH
Phone Number 01745202281
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 MINIMALIST POSHTEL AND SUITES T-47, DEER PARK, HAUZ KHAS NEW DELHI DELHI. 919667774907,
2 .,
3 .,
4 .,
I. Details of Two Reference
In India In BANGLADESH
Name SITARAM BHARTIA LABAID SPECIALIZED HOSPITAL
B-16, QUTAB INSTITUTIONAL
Address AREA, NEW DELHI HOUSE-06, ROAD-04, DHANMONDI, DHAKA
NEW DELHI DELHI
Phone Number 911142111111 8802 586107938
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.
09-MAR-2025 ................................
Date : ...................... Applicant's signature (as in Passport)
