¢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 A¡−hceL¡l£l ¢fa¡l A¡−hceL¡l£l j¡a¡l NZfÊS¡a¿»£ h¡wm¡−cn plL¡l HL¢V l¢Pe 30 ^ 25 HL¢V l¢Pe 30 ^ 25 R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl ¢jx¢jx A¡L¡−ll R¢h ¢jx¢jx A¡L¡−ll R¢h paÉ¡ue Ll − a q − h h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl A¡W¡ ¢c−u m¡N¡−e¡l fl A¡W¡ ¢c−u m¡N¡−e¡l paÉ¡ue Ll−a q−h fl paÉ¡ue Ll−a q−h Affix the photograph Affix applicant’s Affix applicant’s −j¢ne ¢l−Xhm f¡p−f¡VÑ A¡−hce glj Father’s photograph Mother’s photograph here and attest on the Machine Readable Passport Application Form here and attest on the here and attest on the photo 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 f¨lZ Ll¡l f¨−hÑ Ae¤NÊqf§hÑL −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 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) 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 p¡d¡le A¢g¢pu¡m L¤V¯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 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 Profession Nationality

5z* j¡a¡l e¡j x ______−fn¡ x ______S¡a£ua¡ x ______Mother’s Name Profession Nationality

6z 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 AhÙÛ¡ (3) ¢Qq² ¢ce x A¢hh¡¢qa ¢hh¡¢qa ¢hfaÀ£L / ¢hdh¡ a¡m¡LfÊ¡f¹ Marital Status Unmarried Married Widower/Widow Divorced Put (3) in appropriate box 9z* −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 Date of Retirement

10z* SeÈÙÛ¡e (®cn J −Sm¡) x ®c−nl e¡j ______−Sm¡l e¡j ______Place of Birth Country District

11z* SeÈ a¡¢lM x ¢ce j¡p hvpl Date of Birth Day Month Year

12z* ¢mwN (3) ¢Qq² ¢ce x f¥l¦o j¢qm¡ AeÉ¡eÉ Gender (3) in appropriate box Male Female Others

13z* 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* EμQa¡ x −px¢jx Or C¢’ 16z* djÑ x Height cm Abh¡ inch Religion

17z* h¡wm¡−cn£ e¡N¢lL−aÆl p§œ x S¸jp§−œ hwnp§−œ A¢ih¡pe ®cn£uLlZ p¤−œ (¢VL (3) ¢Qq² ¢ce) by birth by descent Migration Naturalization Type of Citizenship ¯hh¡¢qLp§−œ AeÉ¡eÉ, E−õM Ll¦e Put (3) in appropriate box by marriage Others, please specify ______

18z ®~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 Passport No.

19z* 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 (3)¢Qq² ¢ce Put (3) if Permanent Address is same as Present Address

20z* 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 fË−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 Address

22z* 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

®g¡e/gÉ¡„ eðl C-®jCm ¢WL¡e¡ Phone/Fax Number e-mail Address

23z 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 (3) ¢Qq² ¢ce x f¢lhaÑe hÉhq¡−ll Ae¤fk¤š² −ju¡c Eš£ZÑ q¡l¡−e¡ Reason for re apply Conversion Unusable Expired Lost Put (3) in appropriate box

¢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

24z 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

(Copy of National ID) (Copy of Birth RegistrationCertificate) (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) (fË−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¡ 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 pjȤ−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¡¢lM x______

A¡−hceL¡l£l a−bÉl paÉa¡ k¡Q¡C x p¢WL p¢WL 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 ¢ejÀ¢m¢Ma c¢mm¡¢c B−hcef−œ AhnÉC pwk¤š² Ll−a 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 f¡p−f¡VÑ ¢haleL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl

5z A¡−hceL¡l£l f¡p−f¡VÑ fÊ¡¢çl ü¡rl J a¡¢lM f¡a¡-4