¢X.BC.¢f glj - 1 (¢he¡j−¨ mÉ f¡Ê fÉ) A¡−hceL¡l£l HL¢V l¢Pe NZfÊS¡a¿»£ h¡wm¡−cn plL¡l A¡−hceL¡l£l ¢fa¡l A¡−hceL¡l£l j¡a¡l 55 ^ 45 ¢jx¢jx A¡L¡−ll HL¢V l¢Pe 30 ^ 25 HL¢V l¢Pe 30 ^ 25R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl ¢jx¢jx A¡L¡−ll R¢h ¢jx¢jx A¡L¡−ll R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl A¡W¡ ¢c−u m¡N¡−e¡l paÉ¡ue Ll−a q−h −j¢ne ¢l−Xhm f¡p−f¡VÑ A¡−hce glj fl paÉ¡ue Ll−a q−h paÉ¡ue Ll−a q−h Affix the photograph Machine Readable Passport Application Form Affix applicant’shere and attest on the Affix applicant’s Mother’s photograph photo Father’s photograph here and attest on the here and attest on the photo 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 fl¨ Z Ll¡l f¨−hÑ AeN¤ qÊ f§hÑL −no fªù¡u h¢ZaÑ p¡d¡le ¢e−cÑne¡pj§q paLaÑ ¡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 fl¨ Z£uz Serial numbers marked with star (*) marks must be filled in.• œ²¢jL ew 1 hÉa£a AeÉ¡eÉ œ²¢jL Cw−lS£−a (Capital Letters) fl¨ Z£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 eae¤ fe§ x fËc¡e Name of RPO / Bangladesh Mission Application type New Reissue* A¡−hceLa« f¡p−f¡−VlÑ fLÊ «¢a x p¡d¡le A¢g¢pu¡m LV¤ ¯e¢aL Type of passport applied for Ordinary Official Diplomatic* f¡p−f¡VÑ ¢hal−Zl fÊL«¢a x p¡d¡le Sl¦l£ Type of delivery 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 Applicant3z* 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−h¡Ñ 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 ne§ É ®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). fbÊ j 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 Profession Nationality5z* j¡a¡l e¡j x ________________________________ −fn¡ x ___________________S¡a£ua¡ x ____________Mother’s Name Profession Nationality6z ð¡j£/ Ù£» -l e¡j x ________________ _______−fn¡ x ___________________ S¡a£ua¡ x ____________ (fÊ−k¡SÉ q−m) Spouse’s Name Profession Nationality (if applicable)7z A¢ii¡h−Ll e¡j x _____________ __________−fn¡ x ___________________ S¡a£ua¡ x ____________(fÊ−k¡SÉ q−m) Guardian’s Name Profession Nationality(if applicable) f¡a¡-1
8z* ¯hh¡¢qL AhÙ¡Û ( ) ¢Qq² ¢ce x A¢hh¡¢qa ¢hh¡¢qa ¢hfaÀ£L / ¢hdh¡ a¡m¡LfÊ¡f¹Marital Status Unmarried Married Widower/Widow DivorcedPut ( ) in appropriate box9z* −fn¡ x _____________________________________________________________________________ _ProfessionA¢g¢pu¡m f¡p−f¡−VlÑ −r−œ x (In case of Official Passport)A¢g−pl e¡j x ____________________________________________ Ahpl NqÊ −el a¡¢lM x ________________Name of the Office Date of Retirement10z* SeÈÙÛ¡e (®cn J −Sm¡) x ®c−nl e¡j ___________________________ −Sm¡l e¡j ______________________ Place of Birth Country District11z* SeÈ a¡¢lM x ¢ce j¡p hvpl Date of Birth Day Month Year12z* ¢mwN ( ) ¢Qq² ¢ce x f¥l¦o j¢qm¡ AeÉ¡eÉ Gender ( ) in appropriate box Male Female Others13z* SeÈ pecfœ ew x Or Abh¡ Birth Identification Number S¡a£u f¢lQuf−œl ew x National Identification Number14z ¢VA¡CHe (k¢c b¡−L) x -- Tax Identification Number (if available)15z* EµQa¡ x −px¢jx Or C¢’ 16z* djÑ x . cm Abh¡ Height inch Religion ®cn£uLlZ p¤−œ17z* h¡wm¡−cn£ e¡N¢lL−alÆ p§œ x S¸jp§−œ hwnp§−œ A¢ih¡pe Naturalization (¢VL ( ) ¢Qq² ¢ce) by birth by descent MigrationType of Citizenship ¯hh¡¢qLp−§ œ AeÉ¡eÉ, E−õM Ll¦ePut ( ) in appropriate box Others, please specify __________________ _______ by marriage18z ®à~ a e¡N¢lL q−m e¡N¢lLaÆ fcÊ ¡eL¡l£ ®c−nl e¡j x _________________________ f¡p−f¡VÑ ew _________________Name of the other country in case of dual citizenship Passport No.19z* hajÑ ¡e ¢WL¡e¡ x (h¡wm¡−c−n A¡−hc−el ®r−œ f−Ë k¡SÉ) (Applicable only when applying in Bangladesh)PresentAddress 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 hajÑ ¡e ¢WL¡e¡ HLC q−m ¢VL ( )¢Qq² ¢ce Put ( ) if Permanent Address is same as Present Address20z* ÙÛ¡u£ ¢WL¡e¡ x NÊ¡j/h¡p¡ _______________________ ______ l¡Ù¹¡/hÓL/−pƒl________________________ Permanent Village/House Road/Block /Sector Address 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 f−Ë k¡SÉ)Overseas (Applicable only when applying in Bangladesh Missions)Address ¢WL¡e¡ Address ®cn ®g¡e/gÉ¡„ eðl C-®jCm ¢WL¡e¡ Country Phone/Fax Number e-mail Address22z* Sl¦l£ fË−u¡S−e ®k¡N¡−k¡−Nl SeÉ hÉ¢š²l ¢hhlZ x A¡−hceL¡l£l p¡−b pÇfLÑ x (Emergency contact person’s details) Relationship with the applicant e¡j x Name ¢WL¡e¡ x Address ®g¡e/gÉ¡„ eðl C-®jCm ¢WL¡e¡ Phone/Fax Number e-mail Address23z f−§ hÑ fcÊ ¡eLaª f¡p−f¡VÑ eðl (f−Ê k¡SÉ q−m) x Cp¤Él Ù¡Û e J a¡¢lM Previous passport details (if applicable) Place and Date of Issuef¡p−f¡VÑ f¢lha−Ñ el L¡lZ ( ) ¢Qq² ¢ce x f¢lhaÑe hÉhq¡−ll Aef¤ k¤š² −ju¡c Eš£ZÑ q¡l¡−e¡Reason for re apply conversion Unusable Expired LostPut ( ) in appropriate box¢S¢X eðl (fÊ−k¡SÉ ®r−œ) b¡e¡l e¡j a¡¢lMGD No. (if applicable) Name of the Police Station Date24z 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 plL¡l£ A¡−c−nl (¢SJ) g−V¡L¢f (f−Ë k¡SÉ ®r−œ) (Copy of Government Order)(Copy of National ID) (Copy of Birth RegistrationCertificate) ®VL¢eLÉ¡m pe−cl g−V¡L¢fR¡sf−œl (HeJ¢p) L¢f ¢hcÉj¡e f¡p−f¡−VÑl g−V¡L¢f (fË−k¡SÉ ®r−œ)(Copy of Technical Certificates)(fË−k¡SÉ ®r−œ)(Copy of NOC) (f−Ë k¡SÉ ®r−œ)(Copy of Previous Passport)¢VA¡CHe pe−cl g−V¡L¢f ¢f¢XHp/Ahp®ll a¡¢l®Ml fÊj¡efœ(fË−k¡SÉ ®r−œ) (f−Ë k¡SÉ ®r−œ) (PDS/Proof of Retirement Date) (Copy of TIN Certificate)25z* f¡p−f¡−VÑl SeÉ ¢gp Sj¡ pwœ¦¡¿¹ abÉ¡hm£ (−k abÉ…−m¡ f−Ë k¡SÉ q−h) x Payment InformationhÉ¡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¡¢lMBranch Receipt/Transaction No. Date AwN£L¡l e¡j¡ (Declaration)1z A¡¢j nfb L−l hm¢R ®k A¡−hcef−œ fcÊ š ph abÉ paÉ Hhw ®L¡e ¢jbÉ¡ abÉ ¢c−u b¡L−m A¡¢j A¡Ceax cäe£u qhz2z A¡¢j A¡−l¡ f¢Ê 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 faÊ É¡haeÑLl¡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 jaª ɤ 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−hza¡¢lM x _____________________ A¡−hceL¡l£l/A¢ii¡h®Ll (A¡−hceL¡l£ Af¡Ê ç huú q−m) ü¡rl h¡ ¢VfpC (Aef−eu L¡¢m−a) f¡a¡-3
faË Éue (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 fcË ¡eL−l−RezpaÉ¡ueL¡l£l A¡h¡¢pL ¢WL¡e¡ x paÉ¡ueL¡l£l e¡j J ü¡rl a¡¢lM x _____________f¡p−f¡VÑ/S¡a£u f¢lQu fœ ew−V¢m−g¡e eðl (k¢c b¡−L) (p£m ®j¡ql) f¢¤ mn ®i¢l¢g−Lne ¢l−f¡V(Ñ Police Verification Report)f¢¤ mn ®i¢l¢g−Lne eðl x _______________________________________________ a¡¢lM x_____________________A¡−hceL¡l£l a−bÉl paÉa¡ k¡Q¡C x p¢WL p¢WL eup¢WL e¡ q−m L¡lZ (h¡wm¡−cn£ e¡N¢lL ee/p¡S¡f¡Ë ç/ j¡jm¡d£e/ ¢WL¡e¡ p¢WL eu/ AeÉ¡eÉ L¡lZ) x_____________________________ ________________________ _____________________________ fË¢a−hce CpÉL¤ ¡l£ A¢gp¡−ll ü¡rl pf¤ ¡li¡C¢Sw A¢gp¡−ll ü¡rl f¢Ë 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 ¢ejÀ¢m¢Ma c¢mm¡¢c B−hcef−œ AhnÉC pwkš¤ ² Ll−a q−h1z plL¡l£, A¡d¡plL¡l£, ü¡ušn¡¢oa J l¡ø¡Ë uaÄ pwÙ¡Û l Ù¡Û u£ LjLÑ a¡Ñ /LjLÑ ¡l£, Ahplf¡Ë ç plL¡l£ Q¡Ll¤ £S£¢h J a¡−cl ¢eilÑ n£m Ù£» /ü¡j£ Hhw plL¡l£Q¡Ll¤ £S£¢hl 15 (f−el) hvp−ll Lj hu−pl p¿¡¹ e, 5 (f¡y Q)/10 (cn) hvp−ll A¢aœ¦¡¿,¹ pjfeÑ Laª (p¡−lä¡lX) ®cl SeÉ HL¢V glj J AeÉ¡eÉ−cl ®r−œ eae¤f¡p−f¡−VÑl SeÉ 02 (cC¤ ) L¢f fl§ ZLªa f¡p−f¡VÑ glj c¡¢Mm Ll−a q−h z2z Af¡Ë 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¡ueLl−a q−hz3z 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, X¡Ë Ci¡l CaÉ¡¢c) paÉ¡¢ua g−V¡L¢fz4z −k pLm hÉ¢š²NZ f¡p−f¡−VlÑ A¡−hcefœ J R¢h fËaÉ¡ue J paÉ¡ue Ll−a f¡l−he- pwpc pcpÉ, ¢p¢V L−f¡Ñ −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±lL¡E¢¾pmlNZ, ®hplL¡l£ ¢hn¢Ä 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¡øuË ¡š pwÙÛ¡l S¡a£u ®hae ®ú−ml 7j J acd¤ ÄÑ ®NË−Xl LjLÑ a¡Ñ NZ z5z f−Ë k¡SÉ ®r−œ fË¡p¢‰L ¢S J (GO)/ He J ¢p (NOC) c¡¢Mm Ll−a q−h z6z L§V¯e¢aL f¡p−f¡VÑ m¡−il ®k¡NÉ A¡−hceL¡l£NZ−L f§lZLaª glj J pwk¢¤ š²pjq¤ fll¡øË j¿Z» ¡m−u Sj¡ ¢c−a q−h z7z e¡−jl pw¢rçl©−fl f¢lh−aÑ fZ§ Ñl©−f ( ®kje-−j¡x/MD. Hl ÙÛ−m ®j¡q¡jÈc/MOHAMMAD) ¢mM¡ h¡“e£u z ¢nr¡Na h¡ Q¡Ll¤ £p−¤ œ f¡Ë ç fch£pjq§ (−kjeX¡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 fl§ −Zl ®r−œ, HL¡¢dL Awn b¡L−m fË¢a Aw−nl j¡TM¡−e1¢V Ol ne§ É ®l−M fl§ Z 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¡rl2z A¡−hce NqÊ eL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl3z f¡p−f¡VÑ Cpɤ Ae¤−j¡ceL¡l£ LjÑLa¡Ñ l e¡j, BC¢X J ü¡rl4z Cp¤ÉLa« f¡p−f¡VÑ eðlx f¡p−f¡VÑ ¢haleL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl5z A¡−hceL¡l£l f¡p−f¡VÑ fÊ¡¢çl ü¡rl J a¡¢lM f¡a¡-4
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