¢X.BC.¢f glj - 1 (¢he¡j¨−mÉ fÊ¡fÉ)
A¡−hceL¡l£l HL¢V l¢Pe
55 ^ 45 ¢jx¢jx A¡L¡−ll
R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl
paÉ¡ue Ll−a q−h
NZfÊS¡a¿»
¡a¿»£ h¡wm¡−cn plL¡l
h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl
−j¢ne ¢l−Xhm f¡p−f¡VÑ A¡−hce glj
Affix the photograph
here and attest on the
photo
Machine Readable Passport Application Form
A¡−hceL¡l£l ¢fa¡l
HL¢V l¢Pe 30 ^ 25
¢jx¢jx A¡L¡−ll R¢h
A¡W¡ ¢c−u m¡N¡−e¡l fl
paÉ¡ue Ll−a q−h
A¡−hceL¡l£l j¡a¡l
HL¢V l¢Pe 30 ^ 25
¢jx¢jx A¡L¡−ll R¢h
A¡W¡ ¢c−u m¡N¡−e¡l
fl paÉ¡ue Ll−a q−h
Affix applicant’s
Father’s photograph
here and attest on the
photo
Affix applicant’s
Mother’s photograph
here and attest on the
photo
−Lhmj¡œ 15 hvp−ll e£−Q AfË¡çhuú
A¡−hceL¡l£l −r−œ Ef−l¡š² R¢hàu fË−u¡Se z
• A¡−hce fœ¢V f¨lZ Ll¡l f¨−hÑ Ae¤NÊqf§hÑhL
Ñ −no fªù¡u h¢ZÑa p¡d¡le ¢e−cÑne¡pj§q paLÑa¡l p¢qa f¡W Ll²ez
Please read carefully the General Instructions at the last page before filling the form.
• a¡lL¡ (*) ¢Q¢q²a œ²¢jL ew …−m¡ AhnÉ f¨lZ£uz
Z£uz
Serial numbers marked with star (*) marks must be filled in.
• œ²¢jL
œ²¢jL ew 1 hÉa£a AeÉ¡eÉ œ²¢jL Cw−lS£−a (Capital Letters) f¨lZ£u z
Except serial number 1, all other serials must be filled in English (Capital Letters).
* B’¢mL f¡p−f¡VÑ A¢gp/h¡wm¡−cn ¢jne x
* A¡−hc−el fÊL«¢a x
ea¤e
f§ex fËc¡e
Name of RPO / Bangladesh Mission
Application type
New
Reissue
* A¡−hceL«a f¡p−f¡−VÑl fÊL«¢a x
Type of passport applied for
* f¡p−f¡VÑ ¢hal−Zl fÊL«¢a x
Type of delivery
p¡d¡le
A¢g¢pu¡m
L¤V¯e¢aL
Ordinary
Official
Diplomatic
p¡d¡le
Sl¦l£
Regular
Express
hÉ¢š²Na J e¡N¢lLaÄ pwœ²¡ñ abÉ (Personal & Citizenship Details))
1z
A¡−hceL¡l£l e¡j (h¡wm¡u) x ________________________________________________________________
Name of Applicant (in Bengali)
2z*
A¡−hceL¡l£l e¡j x _______________________________________________________________________
Name of Applicant
3z*
B−hceL¡l£l e¡j - A¡f¢e f¡p−f¡−VÑ e¡j −ki¡−h ®cM−a Q¡e ®pi¡−h V¡Cf Ll¦e z p−hÑ¡µQ 48¢V Arl hÉhq¡l Ll¡ k¡−hz
Name of Applicant – Type as you want it to appear in your passport. Maximum 48 characters are allowed.
(e¡−jl ®no¡wn 2u Aw−n ¢mM−a q−h Hhw 1j Aw−n HL¡¢dL Awn b¡L−m fË¢a Aw−nl j¡TM¡−e 1¢V Ol n§eÉ ®l−M f§lZ Ll−a q−h z The last
part of the name should appear in second part. Keep a blank space between two parts of the name).
fÊbj Awn First Part (Given Name)
¢àa£u Awn Second Part (Surname)
4z*
¢fa¡l e¡j x _______________________________ −fn¡ x ___________________ S¡a£ua¡ x _____________
Father’s Name
5z*
Nationality
j¡a¡l e¡j x ________________________________ −fn¡ x ___________________S¡a£ua¡ x ____________
Mother’s Name
6z
Profession
ð¡j£/ Ù»£-l e¡j x ________________
(fÊ−k¡SÉ q−m) Spouse’s Name
Profession
Nationality
_______−fn¡ x ___________________ S¡a£ua¡ x ____________
Profession
Nationality
(if applicable)
7z
A¢ii¡h−Ll e¡j x _____________
(fÊ−k¡SÉ q−m) Guardian’s Name
__________−fn¡ x ___________________ S¡a£ua¡ x ____________
Profession
(if applicable)
f¡a¡-1
Nationality
8z*
9z*
¯hh¡¢qL AhÙÛ¡ () ¢Qq² ¢ce x
A¢hh¡¢qa
¢hh¡¢qa
¢hfaÀ£L / ¢hdh¡
a¡m¡LfÊ¡f¹
Marital Status
Put () in appropriate box
Unmarried
Married
Widower/Widow
Divorced
−fn¡ x _____________________________________________________________________________ _
Profession
A¢g¢pu¡m f¡p−f¡−VÑl −r−œ x (In case of Official Passport)
A¢g−pl e¡j x ____________________________________________ Ahpl NÊq−el a¡¢lM x ________________
Name of the Office
10z*
11z*
12z*
13z*
Date of Retirement
SeÈÙÛ¡e (®cn J −Sm¡) x
®c−nl e¡j ___________________________ −Sm¡l e¡j ______________________
Place of Birth
Country
District
SeÈ a¡¢lM x
¢ce
Date of Birth
Day
j¡p
hvpl
Month
Year
¢mwN () ¢Qq² ¢ce x
f¥l¦o
j¢qm¡
AeÉ¡eÉ
Gender () in appropriate box
Male
Female
Others
SeÈ pecfœ ew x
Birth Identification
Number
Or Abh¡
S¡a£u f¢lQuf−œl ew x
National Identification
Number
14z
¢VA¡CHe (k¢c b¡−L) x
-
Tax Identification
Number (if available)
15z*
17z*
18z
EµQa¡ x
−px¢jx
Height
cm
C¢’
16z*
x
h¡wm¡−cn£ e¡N¢lL−aÆl p§œ x
(¢VL () ¢Qq² ¢ce)
hwnp§−œ
by birth
by descent
Type of Citizenship
Put () in appropriate box
¯hh¡¢qLp§−œ
AeÉ¡eÉ, E−õM Ll¦e
by marriage
Others, please specify __________________ _______
inch
.
Religion
A¢ih¡pe
Migration
®cn£uLlZ p¤−œ
Naturalization
®~àa e¡N¢lL q−m e¡N¢lLaÆ fÊc¡eL¡l£ ®c−nl e¡j x _________________________ f¡p−f¡VÑ ew _________________
Name of the other country in case of dual citizenship
19z*
djÑ
Or
Abh¡
S¸jp§−œ
Passport No.
haÑj¡e ¢WL¡e¡ x
(h¡wm¡−c−n A¡−hc−el ®r−œ fË−k¡SÉ) (Applicable only when applying in Bangladesh)
Present
Address
NÊ¡j / h¡p¡ _____________________ ________ l¡Ù¹¡/hÓL/−pƒl _______________ ______
Village/House
Road/Block /Sector
b¡e¡ ___________________________________ X¡LOl ___________________________
Police Station
Post Office
−Sm¡ __________________________________ −f¡ØV®L¡X
District
Post Code
®g¡e eðl
C-®jCm ¢WL¡e¡
Contact Number
e-mail Address
Øq¡u£ ¢WL¡e¡ J haÑj¡e ¢WL¡e¡ HLC q−m ¢VL ()¢Qq² ¢ce
Put () if Permanent Address is same as Present Address
20z*
ÙÛ¡u£ ¢WL¡e¡ x
NÊ¡j/h¡p¡ _______________________
Permanent
Address
Village/House
______ l¡Ù¹¡/hÓL/−pƒl________________________
Road/Block /Sector
b¡e¡ ___________________________________ X¡LOl ___________________________
Police Station
Post Office
−Sm¡ __________________________________ −f¡ØV−L¡X _________________________
District
Post Code
®g¡e eðl
C-®jCm ¢WL¡e¡
Contact Number
e-mail Address
f¡a¡-2
21z
¯h−c¢nL ¢WL¡e¡ x (¯h−c¢nL ¢WL¡e¡ −Lhmj¡œ h¡wm¡−cn ¢jn−e A¡−hc−el ®r−œ fË−k¡SÉ)
Overseas
Address
(Applicable only when applying in Bangladesh Missions)
¢WL¡e¡
Address
22z*
®cn
®g¡e/gÉ¡„ eðl
C-®jCm ¢WL¡e¡
Country
Phone/Fax Number
e-mail Address
Sl¦l£ fË−u¡S−e ®k¡N¡−k¡−Nl SeÉ hÉ¢š²l ¢hhlZ x
(Emergency contact person’s details)
e¡j x
A¡−hceL¡l£l p¡−b pÇfLÑ x
Name
Relationship with the applicant
¢WL¡e¡ x
Address
23z
24z
25z*
®g¡e/gÉ¡„ eðl
C-®jCm ¢WL¡e¡
Phone/Fax Number
e-mail Address
f§−hÑ fÊc¡eLªa f¡p−f¡VÑ eðl (fÊ−k¡SÉ q−m) x
Cp¤Él ÙÛ¡e J a¡¢lM
Previous passport details (if applicable)
Place and Date of Issue
f¡p−f¡VÑ f¢lhaÑ−el L¡lZ () ¢Qq² ¢ce x
f¢lhaÑe
hÉhq¡−ll Ae¤fk¤š²
−ju¡c Eš£ZÑ
q¡l¡−e¡
Reason for re apply
Put () in appropriate box
conversion
Unusable
Expired
Lost
¢S¢X eðl (fÊ−k¡SÉ ®r−œ)
b¡e¡l e¡j
a¡¢lM
GD No. (if applicable)
Name of the Police Station
Date
A¡−hce f−œl p¡−b pwk¤š² c¢mm¡¢c x
(Enclosures attached with the application form)
S¡a£u f¢lQuf−œl g−V¡L¢f
SeÈ ¢ehåe pe−cl g−V¡L¢f
(Copy of National ID)
(Copy of Birth RegistrationCertificate)
plL¡l£ A¡−c−nl (¢SJ) g−V¡L¢f
(fË−k¡SÉ ®r−œ) (Copy of Government Order)
R¡sf−œl (HeJ¢p) L¢f
¢hcÉj¡e f¡p−f¡−VÑl g−V¡L¢f
®VL¢eLÉ¡m pe−cl g−V¡L¢f
(fË−k¡SÉ ®r−œ)(Copy of NOC)
(fË−k¡SÉ ®r−œ)(Copy of Previous Passport)
(fË−k¡SÉ ®r−œ)(Copy of Technical Certificates)
¢VA¡CHe pe−cl g−V¡L¢f
¢f¢XHp/Ahp®ll a¡¢l®Ml fÊj¡efœ
(fË−k¡SÉ ®r−œ)
(Copy of TIN Certificate)
(fË−k¡SÉ ®r−œ) (PDS/Proof of Retirement Date)
f¡p−f¡−VÑl SeÉ ¢gp Sj¡ pwœ¦¡¿¹ abÉ¡hm£ (−k abÉ…−m¡ fË−k¡SÉ q−h) x Payment Information
hÉ¡wL/h¡wm¡−cn ¢jne
Sj¡Lªa ¢g Hl f¢lj¡e (V¡L¡/j¡¢LÑe Xm¡l )
Name of the Bank/Bangladesh Mission
Amount deposited (US$ in case of Bangladesh Missions)
n¡M¡
l¢nc ew
a¡¢lM
Branch
Receipt/Transaction No.
Date
AwN£L¡l e¡j¡ (Declaration)
)
(
1z
A¡¢j nfb L−l hm¢R ®k A¡−hcef−œ fÊcš ph abÉ paÉ Hhw ®L¡e ¢jbÉ¡ abÉ ¢c−u b¡L−m A¡¢j A¡Ceax cäe£u qhz
2z
A¡¢j A¡−l¡ fÊ¢a‘¡ Ll¢R A¡¢j/A¡j¡l p¿¹¡e h¡ ®f¡oÉ, ®k ®L¡e L¡l−Z Ai¡hNÊÙÛ q−u fs−m ¢h−cn ®b−L A¡j¡−L Abh¡ A¡j¡l ®f¡oÉ−L ®c−n fÊaÉ¡haÑe
Ll¡l ®r−œ k¡ha£u MlQ f¢l−n¡−d h¡dÉ b¡Lh Hhw ¢h−c−n A¡j¡l/A¡j¡l p¿¹¡e h¡ ®f¡−oÉl jªaɤ OV−m jl−c−ql f¢lhqe MlQ A¡j¡l °hd Ešl¡¢dL¡l£/A¡j¡l L¡R
®b−L A¡c¡u−k¡NÉ q−hz
a¡¢lM x _____________________
A¡−hceL¡l£l/A¢ii¡h®Ll (A¡−hceL¡l£ AfÊ¡ç huú q−m)
ü¡rl h¡ ¢VfpC (Aef−eu L¡¢m−a)
f¡a¡-3
fËaÉue (Certification)
)
(
A¡j¡l ‘¡e J ¢hnÄ¡pj−a Ef−l h¢ZÑa abÉ paÉ Hhw B−hceL¡l£
hvpl k¡hv A¡j¡l f¢l¢Qaz ¢a¢e A¡j¡l pjÈ−¤ M A¡−hcef−œ ü¡rl / ¢VfpC fËc¡e
L−l−Rez
paÉ¡ueL¡l£l A¡h¡¢pL ¢WL¡e¡ x
paÉ¡ueL¡l£l e¡j J ü¡rl
f¡p−f¡VÑ/S¡a£u f¢lQu fœ ew
a¡¢lM x _____________
−V¢m−g¡e eðl (k¢c b¡−L)
(p£m ®j¡ql)
f¤¢mn ®i¢l¢g−Lne ¢l−f¡VÑ(Police Verification Report))
f¤¢mn ®i¢l¢g−Lne eðl x _______________________________________________
A¡−hceL¡l£l a−bÉl paÉa¡ k¡Q¡C x
p¢WL
a¡¢lM x_____________________
p¢WL eu
eu
p¢WL e¡ q−m L¡lZ (h¡wm¡−cn£ e¡N¢lL ee/p¡S¡fË¡ç/ j¡jm¡d£e/ ¢WL¡e¡ p¢WL eu/ AeÉ¡eÉ L¡lZ) x
_____________________________
________________________
_____________________________
fË¢a−hce CpɤL¡l£ A¢gp¡−ll ü¡rl
p¤f¡li¡C¢Sw A¢gp¡−ll ü¡rl
fË¢a−hce fÊ¢aü¡rlL¡l£ A¢gp¡−ll ü¡rl
(f¤¢mn BC¢X J p£m)
(f¤¢mn BC¢X J p£m)
(f¤¢mn BC¢X J p£m)
¢e−cÑne¡ (General
Instruction))
(
A¡−hceL¡l£−L ¢ej
¢m¢Ma c¢mm¡¢c B−hcef−œ AhnÉC pwk¤š² Ll−a q−h
¢ejÀ¢m¢Ma
q−h
1z plL¡l£, A¡d¡plL¡l£, ü¡ušn¡¢oa J l¡øË¡uaÄ pwÙÛ¡l ÙÛ¡u£ LjÑLaÑ¡/LjÑL¡l£, AhplfË¡ç plL¡l£ Q¡L¤l£S£¢h J a¡−cl ¢eiÑln£m Ù»£/ü¡j£ Hhw plL¡l£
Q¡L¤l£S£¢hl 15 (f−el) hvp−ll Lj hu−pl p¿¹¡e, 5 (fy¡Q)/10 (cn) hvp−ll A¢aœ¦¡¿¹, pjfÑeLªa (p¡−lä¡lX) ®cl SeÉ HL¢V glj J AeÉ¡eÉ−cl ®r−œ ea¤e
f¡p−f¡−VÑl SeÉ 02 (c¤C) L¢f f§lZLªa f¡p−f¡VÑ glj c¡¢Mm Ll−a q−h z
2z AfË¡çhuú (15 hR−ll Lj) A¡−hceL¡l£l −r−®œ A¡−hceL¡l£l ¢fa¡ J j¡a¡l HL¢V L−l l¢Pe R¢h (30 ^ 25 ¢jx¢jx) R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl paÉ¡ue
Ll−a q−hz
3z S¡a£u f¢lQufœ Abh¡ SeÈ ¢ehåe pec Hhw fË−k¡SÉ ®r−œ fË¡p¢‰L ®VL¢eLÉ¡m pecpj§−ql (−kje X¡š²¡l, C¢”¢eu¡l, XË¡Ci¡l CaÉ¡¢c) paÉ¡¢ua g−V¡L¢fz
4z −k pLm hÉ¢š²NZ f¡p−f¡−VÑl A¡−hcefœ J R¢h fËaÉ¡ue J paÉ¡ue Ll−a f¡l−he- pwpc pcpÉ, ¢p¢V L−fÑ¡−ln−el ®jul, ®Xf¤¢V ®jul J L¡E¢¾pmlNZ,
®N−S−VX LjÑLaÑ¡, f¡h¢mL ¢hnÄ¢hcÉ¡m−ul ¢nrL, Ef−Sm¡ f¢lo−cl ®Qu¡ljÉ¡e J i¡Cp ®Qu¡ljÉ¡e, CE¢eue f¢lo−cl ®Qu¡ljÉ¡e, ®f±lpi¡l ®jul J ®f±l
L¡E¢¾pmlNZ, ®hplL¡l£ ¢hnÄ¢hcÉ¡m−ul AdÉ¡fL, −hplL¡l£ L−m−Sl AdÉr, −hplL¡l£ EµQ ¢hcÉ¡m−ul fËd¡e ¢nrL, S¡a£u °c¢eL f¢œL¡l pÇf¡cL, ®e¡V¡l£
f¡h¢mL J A¡d¡plL¡l£/ü¡ušn¡¢pa/l¡øËu¡š pwÙÛ¡l S¡a£u ®hae ®ú−ml 7j J ac¤dÄÑ ®NË−Xl LjÑLaÑ¡NZ z
5z fË−k¡SÉ ®r−œ fË¡p¢‰L ¢S J (GO)/ He J ¢p (NOC) c¡¢Mm Ll−a q−h z
6z L§V¯e¢aL f¡p−f¡VÑ m¡−il ®k¡NÉ A¡−hceL¡l£NZ−L f§lZLªa glj J pwk¤¢š²pj¤q fll¡øË j¿»Z¡m−u Sj¡ ¢c−a q−h z
7z e¡−jl pw¢rçl©−fl f¢lh−aÑ f§ZÑl©−f ( ®kje-−j¡x/MD. Hl ÙÛ−m ®j¡q¡jÈc/MOHAMMAD) ¢mM¡ h¡“e£u z ¢nr¡Na h¡ Q¡L¤l£p¤−œ fË¡ç fch£pj§q (−kje
X¡š¦¡l, C¢”¢eu¡l, Xƒl, ¢fHCQ¢X CaÉ¡¢c) e¡−jl Awn ¢q−ph f¢lN¢Za q−h e¡ z gl−jl œ¦¢jL ew 3 f§l−Zl ®r−œ, HL¡¢dL Awn b¡L−m fË¢a Aw−nl j¡TM¡−e
1¢V Ol n§eÉ ®l−M f§lZ Ll−a q−h z A¡−hceL¡l£l ¢fa¡, j¡a¡, ü¡j£/Ù»£ jªa q−mJ, a¡l/a¡−cl e¡−jl f§−hÑ "jªa/jlýj/Late' ®mM¡ k¡−h e¡ z
A¢g−pl hÉhq¡−ll SeÉ (FOR OFFICIAL USE ONLY)
1z
abÉ pwNËqL¡l£ (Af¡−lVl) Hl e¡j, BC¢X J ü¡rl
2z
A¡−hce NÊqeL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl
3z
f¡p−f¡VÑ Cpɤ Ae¤−j¡ceL¡l£ LjÑLaÑ¡l e¡j, BC¢X J ü¡rl
4z
Cp¤ÉL«a f¡p−f¡VÑ eðlx
5z
A¡−hceL¡l£l f¡p−f¡VÑ fÊ¡¢çl ü¡rl J a¡¢lM
f¡p−f¡VÑ ¢haleL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl
f¡a¡-4