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    081024INWSYY

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    vsspprtcentre

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    © All Rights Reserved
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    081024INWSYY

    Uploaded by

    vsspprtcentre
    22 views3 pages

    Original Title

    081024INWSYY (2)

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    22 views3 pages

    081024INWSYY

    Uploaded by

    vsspprtcentre

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    © All Rights Reserved
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    You are on page 1of 3

    APPLICATION FORM

    ( Visa Extension )

    081024INWSYY

    Application ID No. 081024INWSYY Final Submission Date Tue Oct 08 17:47:11 IST 2024

    FOR OFFICE USE ONLY

    Reg. No. B 0 0 5 B G D 2 0 2 4

    Personal Details
    Surname RAHMAN
    Given Name SHAID Paste your
    Sex Male Date of Birth 20/10/1973 Height (in cm) 0 Recent passport size
    Age as on today Year(s) 50 Month(s) 11 Day(s) 30 photograph here
    Place of Birth DHAKA,DHAKA,BANGLADESH
    Father's Name HABIBUR RAHMAN
    Mother's Name JAHURA KHATUN
    Spouse's Name NASRIN AKTER
    Religion ISLAM Any Identification mark(s) preferably MOLE
    visible

    Present nationality BANGLADESH Previous nationality


    Manner of acquiring present nationality Birth
    Date of acquiring present nationality
    Whether holding dual NO
    nationality? If yes, Name of the country of second nationality
    provide the following:- Passport No. of second country
    Date of Issue
    Date of Expiry
    Whether travelled on this passport earlier to
    India

    Whether person of Indian Origin NO

    Address of last residence (Outside India)


    Address HOUSE NO-19,BLOCK B,MIRPUR,MIRPUR,DHAKA
    City DHAKA Country BANGLADESH

    Address intended for longer stay in India (Registration)


    Address 14/1 COLLIN LANE
    City/ District KOLKATA State WEST BENGAL
    Pin Code 700016
    Phone Number Mobile Number
    Any Other Address in India
    Address
    City/ District State
    Pin Code
    Phone Number Mobile Number
    Email/Occupation/Profession Details
    E-Mail Id vsspprtcentre@gmail.com
    Profession/Occupation BUSINESS

    Passport Details
    Passport Number EH0287822 Place of Issue BANGLADESH, DHAKA
    Date of Issue 08/12/2020 Expiry Date 07/12/2025

    Visa Details
    Visa Number VN1061711 Place of Issue BANGLADESH, DHAKA
    Date of Issue 04/04/2024 Expiry Date 03/10/2024
    Valid For Triple Entry Visa Type MEDICAL VISA
    Special endorsement, if any

    Organization/Company/Institute/Hospital Details
    Name APOLLO MULTISPECIALITY HOSPITALS
    Address 58, CANAL CIRCULAR RD, KADAPARA, PHOOL BAGAN, KANKURGACHI,

    Page 1 of 3
    081024INWSYY
    Application ID No. 081024INWSYY

    State WEST BENGAL City KOLKATA


    Telephone Number Email ID
    Employer EPFO ID Establishment ID
    Arrival Details
    Place of embarkation/boarding for India DHAKA,DHAKA,BANGLADESH
    Date of arrival in India 14/06/2024
    Place of disembarkation/arrival in India HARIDASPUR
    Mode of Journey Road Flight/ Ship/ Bus/ Train No.
    Purpose of visit to India Medical Treatment of self

    Previous Registration Details in India


    Registration Number Place of Registration Visa Type Duration From To
    Details of family members/attendant/dependents, if any accompanying.
    Name Nationality Passport Number Relationship
    Person to be contacted in Case of Emergency
    Name Relationship
    Address City
    Country Phone Number
    Category Others

    Military service details


    Organisation Designation
    Rank Place of Last Posting
    Country of Last Posting

    Current Registration Details


    Are you registered in current locality FRRO/FRO in the current visit? NO Current
    Registration No.

    Current Extension Details


    Have you got extended visa in current visit in current locality NO Current
    FRRO/FRO? Extension No.

    Visa Extension Details


    Whether previously in India? NO
    Whether permission to stay in India has been previously refused? NO
    Whether permission to extend stay in India has been previously granted? NO
    Period of Extension requried Year(s) Month(s) 6 Day(s)
    Reason for extension TREATMENT
    In case of Missionary - Nature of work
    Medical Certificate No.

    Signature of the Applicant


    Date_ _ _ _ _ _ _ _ _ _ _ _ _

    Page 2 of 3
    081024INWSYY
    Application ID No. 081024INWSYY

    List of mandatory and non mandatory documents

    Mandatory Documents.
    1. Photo : Applicant's Photo
    2. Residence proof : Updated Form 'C' from Hotel or Lodge or hospital/ Registered or Notarized Lease Deed in case staying in a rented accommodation /Electricity Bill or Landline
    Telephone Bill or Municipal Bill of the landlord in case of staying in a house of a friend or a relative along with a declaration from the landlord and copy of photo-ID of the landlord and Tenant Police
    Verification

    3. Visa : Indian Visa


    4. Medical certificate : Medical Certificate from recognized/reputed hospital where treatment is being taken, mentioning type of ailment, duration of treatment with treating doctor’s signature
    and stamp and doctor’s registration no. with state code. Medical Certificate also to mention Name, Nationality and Passport No. of Medical Attendant, if any

    5. Registration Certificate and Stay Visa : FRRO/ FRO Registration Certificate and Stay Visa (if any)
    6. Passport : Bio-Data page of Passport along with page bearing last Indian Immigration arrival stamp

    Registration office address

    Office Name : FRRO Kolkata


    Address : Office of the FRRO, 237 Jagadish Chandra Bose Road
    City/District : KOLKATA
    State : WEST BENGAL
    Pin Code :
    Phone Number : 033-22818640

    Office opening time: 12.00 closing time: 17.30

    There is no need to submit hard copy to concerned


    FRRO/FRO

    Page 3 of 3

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