¢X.BC.

¢f glj - 1 (¢he¡j¨mÉ fÊ¡fÉ)

A¡hceL¡l£l HL¢V l
¢Pe 55 ^ 45 ¢jx¢jx A¡hceL¡l£l ¢fa¡l A¡hceL¡l£l j¡a¡l
A¡L¡ll R¢h A¡W¡ ¢cu NZfÊS¡a¿»£ h¡wm¡cn plL¡l HL¢V l¢Pe 30 ^
25 ¢jx¢jx A¡L¡ll R
HL¢V l¢Pe 30 ^
25 ¢jx¢jx A¡L¡ll
m¡N¡e¡l fl paÉ¡ue Lla h¢ql¡Nje J f¡pf¡VÑ A¢dcçl ¢h A¡W¡ ¢cu R¢h A¡W¡ ¢cu
qh m¡N¡e¡l fl paÉ¡ue m¡N¡e¡l fl paÉ¡ue
j¢ne ¢lXhm f¡pf¡VÑ A¡hce glj Lla qh
Affix applicant’s
Lla qh
Affix applicant’s
Affix the photograph Machine Readable Passport Application Form Father’s photograph Mother’s photograph
here and attest on the here and attest on the here and attest on the
photo photo photo
Lhmj¡œ 15 hvpll e£Q AfË¡çhuú A¡-
hceL¡l£l rœ Efl¡š² R¢hàu fËu¡Se z

 A¡hce fœ¢V f¨lZ Ll¡l f¨hÑ Ae¤NÊqf§hÑL no fªù¡u h¢ZÑa p¡d¡le ¢ecÑne¡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 CwlS£a (Capital Letters) f¨lZ£u z
Except serial number 1, all other serials must be filled in English (Capital Letters).

* B’¢mL f¡pf¡VÑ A¢gp/h¡wm¡cn ¢jne x * A¡hcel fÊL«¢a x ea¤e

f§ex fËc¡e
Name of RPO / Bangladesh Mission Application type New Reissue

* A¡hceL«a f¡pf¡VÑl fÊL«¢a x p¡d¡le A¢g¢pu¡m L¤V¯e¢aL

Type of passport applied for Ordinary Official Diplomatic

* f¡pf¡VÑ ¢halZl 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* BhceL¡l£l e¡j - A¡f¢e f¡pf¡VÑ e¡j ki¡h ®cMa Q¡e ®pi¡h V¡Cf Ll¦e z phÑ¡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 Awn ¢mMa qh Hhw 1j Awn HL¡¢dL Awn b¡Lm fË¢a Awnl j¡TM¡e 1¢V Ol n§eÉ ®lM f§lZ Lla qh
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

____________
(fÊk¡SÉ qm) Spouse’s Name Profession Nationality

f¡a¡-1
 (if applicable)

7z A¢ii¡hLl e¡j x _____________ __________fn¡ x ___________________ S¡a£ua¡ x ____________

(fÊk¡SÉ qm) Guardian’s Name Profession Nationality
(if applicable)

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* fn¡ x _____________________________________________________________________________ _
Profession
A¢g¢pu¡m f¡pf¡VÑl rœ x (In case of Official Passport)
A¢gpl e¡j x ____________________________________________ Ahpl NÊqel a¡¢lM x
________________
Name of the Office Date of Retirement

10z* SeÈÙÛ¡e (®cn J Sm¡) x ®cnl 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 () ¢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¢lQufœl 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¢lLaÆl 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, EõM Ll¦e
Put () in appropriate box by marriage Others, please specify __________________ _______
18z ®~àa e¡N¢lL qm e¡N¢lLaÆ fÊc¡eL¡l£ ®cnl e¡j x _________________________ f¡pf¡VÑ ew
_________________
Name of the other country in case of dual citizenship Passport No.
19z* haÑj¡e ¢WL¡e¡ x (h¡wm¡cn A¡hcel ®rœ fËk¡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
f¡a¡-2
 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 qm ¢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¡ØVL¡X _________________________

District Post Code
®g¡e eðl C-®jCm ¢WL¡e¡

Contact Number e-mail Address

21z ¯hc¢nL ¢WL¡e¡ x (¯hc¢nL ¢WL¡e¡ Lhmj¡œ h¡wm¡cn ¢jne A¡hcel ®rœ fËk¡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£ fËu¡Se ®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¡pf¡VÑ eðl (fÊk¡SÉ qm) x Cp¤Él ÙÛ¡e J a¡¢lM

Previous passport details (if applicable) Place and Date of Issue

f¡pf¡VÑ f¢lhaÑel 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 (fÊk¡SÉ ®rœ) b¡e¡l e¡j a¡¢lM

GD No. (if applicable) Name of the Police Station Date

24z A¡hce fœl p¡b pwk¤š² c¢mm¡¢c x

(Enclosures attached with the application form)
S¡a£u f¢lQufœl gV¡L¢f SeÈ ¢ehåe pecl gV¡L¢f plL¡l£ A¡cnl (¢SJ) gV¡L¢f
(Copy of National ID) (Copy of Birth RegistrationCertificate) (fËk¡SÉ ®rœ) (Copy of Government
Order)

f¡a¡-3
 R¡sfœl (HeJ¢p) L¢f ¢hcÉj¡e f¡pf¡VÑl gV¡L¢f ®VL¢eLÉ¡m pecl gV¡L¢f
(fËk¡SÉ ®rœ)(Copy of NOC) (fËk¡SÉ ®rœ)(Copy of Previous Passport) (fËk¡SÉ ®rœ)(Copy of Technical
Certificates)

¢VA¡CHe pecl gV¡L¢f ¢f¢XHp/Ahp®ll a¡¢l®Ml fÊj¡efœ

(fËk¡SÉ ®rœ) (fËk¡SÉ ®rœ) (PDS/Proof of Retirement Date)
(Copy of TIN Certificate)

25z* f¡pf¡VÑl SeÉ ¢gp Sj¡ pwœ¦¡¿¹ abÉ¡hm£ (k abÉ…m¡ fËk¡SÉ qh) 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 Ll hm¢R ®k A¡hcefœ fÊcš ph abÉ paÉ Hhw ®L¡e ¢jbÉ¡ abÉ ¢cu b¡Lm 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¡lZ Ai¡hNÊÙÛ qu fsm ¢hcn ®bL A¡j¡L Abh¡ A¡j¡l
®f¡oÉL ®cn fÊaÉ¡haÑe Ll¡l ®rœ k¡ha£u MlQ f¢ln¡d h¡dÉ b¡Lh Hhw ¢hcn A¡j¡l/A¡j¡l p¿¹¡e h¡ ®f¡oÉl jªaɤ OVm jlcql f¢lhqe
MlQ A¡j¡l °hd Ešl¡¢dL¡l£/A¡j¡l L¡R ®bL A¡c¡uk¡NÉ qhz

a¡¢lM x _____________________ A¡hceL¡l£l/A¢ii¡h®Ll (A¡hceL¡l£ AfÊ¡ç huú qm)

ü¡rl h¡ ¢VfpC (Aefeu L¡¢ma)

f¡a¡-4
 fËaÉue (Certification)

A¡j¡l ‘¡e J ¢hnÄ¡pja Efl h¢ZÑa abÉ paÉ Hhw BhceL¡l£ hvpl k¡hv A¡j¡l f¢l¢Qaz ¢a¢e A¡j¡l pjȤM A¡hcefœ
ü¡rl / ¢VfpC fËc¡e LlRez

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¢mg¡e eðl (k¢c b¡L) (p£m ®j¡ql)

f¤¢mn ®i¢l¢gLne ¢lf¡VÑ(Police Verification Report)

f¤¢mn ®i¢l¢gLne eðl x _______________________________________________ a¡¢lM
x_____________________

A¡hceL¡l£l abÉl paÉa¡ k¡Q¡C x

p¢WL p¢WL eu

p¢WL e¡ qm 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¢ahce CpɤL¡l£ A¢gp¡ll ü¡rl p¤f¡li¡C¢Sw A¢gp¡ll ü¡rl fË¢ahce 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)

¢ecÑne¡ (General Instruction)

A¡hceL¡l£L ¢ejÀ¢m¢Ma c¢mm¡¢c Bhcefœ AhnÉC pwk¤š² Lla qh

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 (fel) hvpll Lj hupl p¿¹¡e, 5 (fy¡Q)/10 (cn) hvpll A¢aœ¦¡¿¹, pjfÑeLªa (p¡-
lä¡lX) ®cl SeÉ HL¢V glj J AeÉ¡eÉcl ®rœ ea¤e f¡pf¡VÑl SeÉ 02 (c¤C) L¢f f§lZLªa f¡pf¡VÑ glj c¡¢Mm Lla qh z
2z AfË¡çhuú (15 hRll Lj) A¡hceL¡l£l r®œ A¡hceL¡l£l ¢fa¡ J j¡a¡l HL¢V Ll l¢Pe R¢h (30 ^ 25 ¢jx¢jx) R¢h A¡W¡ ¢cu m¡N¡e¡l
fl paɡue Lla qhz
3z S¡a£u f¢lQufœ Abh¡ SeÈ ¢ehåe pec Hhw fËk¡SÉ ®rœ fË¡p¢‰L ®VL¢eLÉ¡m pecpj§ql (kje X¡š²¡l, C¢”¢eu¡l, XË¡Ci¡l
CaÉ¡¢c) paÉ¡¢ua gV¡L¢fz
4z k pLm hÉ¢š²NZ f¡pf¡VÑl A¡hcefœ J R¢h fËaÉ¡ue J paÉ¡ue Lla f¡lhe- pwpc pcpÉ, ¢p¢V LfÑ¡lnel ®jul, ®Xf¤¢V ®jul J
L¡E¢¾pmlNZ, ®NSVX LjÑLaÑ¡, f¡h¢mL ¢hnÄ¢hcÉ¡mul ¢nrL, EfSm¡ f¢locl ®Qu¡ljÉ¡e J i¡Cp ®Qu¡ljÉ¡e, CE¢eue f¢locl
®Qu¡ljÉ¡e, ®f±lpi¡l ®jul J ®f±l L¡E¢¾pmlNZ, ®hplL¡l£ ¢hnÄ¢hcÉ¡mul AdÉ¡fL, hplL¡l£ LmSl AdÉr, hplL¡l£ EµQ
¢hcÉ¡mul 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
®úml 7j J ac¤dÄÑ ®NËXl LjÑLaÑ¡NZ z
5z fËk¡SÉ ®rœ fË¡p¢‰L ¢S J (GO)/ He J ¢p (NOC) c¡¢Mm Lla qh z
6z L§V¯e¢aL f¡pf¡VÑ m¡il ®k¡NÉ A¡hceL¡l£NZL f§lZLªa glj J pwk¤¢š²pj¤q fll¡øË j¿»Z¡mu Sj¡ ¢ca qh z
7z e¡jl pw¢rçl©fl f¢lhaÑ f§ZÑl©f ( ®kje-j¡x/MD. Hl ÙÛm ®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 ¢qph f¢lN¢Za qh e¡ z gljl œ¦¢jL ew 3 f§lZl ®rœ,
HL¡¢dL Awn b¡Lm fË¢a Awnl j¡TM¡e 1¢V Ol n§eÉ ®lM f§lZ Lla qh z A¡hceL¡l£l ¢fa¡, j¡a¡, ü¡j£/Ù»£ jªa qmJ, a¡l/a¡cl e¡jl
f§hÑ "jªa/jlýj/Late' ®mM¡ k¡h e¡ z

A¢gpl hÉhq¡ll SeÉ (FOR OFFICIAL USE ONLY)

1z abÉ pwNËqL¡l£ (Af¡lVl) Hl e¡j, BC¢X J ü¡rl

f¡a¡-5
2z A¡hce NÊqeL¡l£ A¢gp¡ll e¡j, BC¢X J ü¡rl

3z f¡pf¡VÑ Cpɤ Ae¤j¡ceL¡l£ LjÑLaÑ¡l e¡j, BC¢X J ü¡rl

4z Cp¤ÉL«a f¡pf¡VÑ eðlx f¡pf¡VÑ ¢haleL¡l£ A¢gp¡ll e¡j, BC¢X J ü¡rl

5z A¡hceL¡l£l f¡pf¡VÑ fÊ¡¢çl ü¡rl J a¡¢lM

f¡a¡-6