¢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
R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl NZfÊS¡a¿»
¡a¿»£ h¡wm¡−cn plL¡l HL¢V l¢Pe 30 ^ 25
¢jx¢jx A¡L¡−ll R¢h
HL¢V l¢Pe 30 ^ 25
¢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 −j¢ne ¢l−Xhm f¡p−f¡VÑ A¡−hce glj Affix applicant’s
Father’s photograph
Affix applicant’s
Mother’s photograph
here and attest on the
photo
Machine Readable Passport Application Form here and attest on the
photo
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 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* JARINA BEGUM
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)
J A R I N A
¢àa£u Awn Second Part (Surname)
B E G UM
4z* MONIR UDDIN AHMED
¢fa¡l e¡j x _______________________________ DOCTOR
−fn¡ x ___________________ BANGLADESHI
S¡a£ua¡ x _____________
Father’s Name Profession Nationality

5z* SALATUNNESA
j¡a¡l e¡j x ________________________________ HOUSEWIFE
−fn¡ x ___________________S¡a£ua¡ BANGLADESHI
x ____________
Mother’s Name Profession Nationality

6z MD. MONJURUL ALAM

ð¡j£/ Ù»£-l e¡j x ________________ BUSINESS
_______−fn¡ x ___________________ BANGLADESHI
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¡ (
) ¢Qq² ¢ce x A¢hh¡¢qa ¢hh¡¢qa ¢hfaÀ£L / ¢hdh¡ a¡m¡LfÊ¡f¹
Marital Status Unmarried Married Widower/Widow Divorced
Put (
) in appropriate box
9z* HOUSEWIFE
−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 BANGLADESH
®c−nl e¡j ___________________________ CHITTAGONG
−Sm¡l e¡j ______________________
Place of Birth Country District

11z* SeÈ a¡¢lM x ¢ce j¡p hvpl

Date of Birth 1 8 Day 0 3 Month 1 9 6 9 Year

12z* ¢mwN (
) ¢Qq² ¢ce x f¥l¦o j¢qm¡ AeÉ¡eÉ

Gender (
) 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
2 8 2 5 7 2 7 4 5 2
Number

14z ¢VA¡CHe (k¢c b¡−L) x - -

Tax Identification
Number (if available)
15z* EµQa¡ x −px¢jx Or C¢’ 16z* djÑ x ISLAM .
1 6 3 6 4
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 (
) ¢Qq² ¢ce) by birth by descent Migration Naturalization
Type of Citizenship ¯hh¡¢qLp§−œ AeÉ¡eÉ, E−õM Ll¦e
Put (
) 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¡ _____________________
MOWLANA MONJIL, PADMA PUKUR
________ SARAIPARA
PAR. l¡Ù¹¡/hÓL/−pƒl _______________ ______
Village/House Road/Block /Sector
PAHARTALI
b¡e¡ ___________________________________ PAHARTALI - 4202
X¡LOl ___________________________
Police Station Post Office
CHATTOGRAM
−Sm¡ __________________________________ −f¡ØV®L¡X PAHARTALI - 4202
District Post Code
®g¡e eðl 01747525513, 01914751018 C-®jCm ¢WL¡e¡ [email protected]
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¡ _______________________ ______ 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 MD. FAZLUL QUADER A¡−hceL¡l£l p¡−b pÇfLÑ x SON
Name Relationship with the applicant
¢WL¡e¡ x MOWLANA MOSTOFER BARI, PADMA PUKUR PAR.
Address
SARAIPARA, WARD NO 12, PAHARTALI-4202, CHATTOGRAM

®g¡e/gÉ¡„ eðl 01818517316 C-®jCm ¢WL¡e¡ [email protected]

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 (
) ¢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 (
) 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 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¡¢lM x_____________________

A¡−hceL¡l£l a−bÉl paÉa¡ k¡Q¡C x

p¢WL 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
¢ejÀ¢m¢Ma
¢m¢Ma c¢mm¡¢c B−hcef−œ AhnÉC pwk¤š² Ll−a q−h 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