¢X.BC.

¢f glj - 1
A¡−hceL¡l£l HL¢V l¢Pe 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 ^
R¢h A¡W¡ ¢c−u ¢jx¢jx A¡L¡−ll R¢h 25 ¢jx¢jx A¡L¡−ll R
m¡N¡−e¡l fl paÉ¡ue A¡W¡ ¢c−u ¢h
m¡N¡−e¡l fl A¡W¡ ¢c−u
Ll−a q−h m¡N¡−e¡l fl
paÉ¡ue Ll−a q−h
Affix applicant’s paÉ¡ue Ll−a q−h
Affix the photograph Father’s photograph Affix applicant’s
here and attest on the Mother’s photograph
here and attest on the photo 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
(¢he¡j−¨ mÉ fÊ¡fÉ)

NZfÊS¡a¿»£ h¡wm¡−cn plL¡l

h¢ql¡Nje J f¡p−f¡V Ñ A¢dcçl

−j¢ne ¢l−Xhm f¡p−f¡V ÑA¡−hce glj

Machine Readable Passport Application Form

• A¡−hce fœ¢V f¨lZ Ll¡l f¨−h Ñ AeN¤ Êqf§hÑL −no fªù¡u h¢ZaÑ 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) fl¨ Z£u z Except serial number 1, all other serials must
be filled in English (Capital Letters).

* B’¢mL f¡p−f¡V Ñ 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¡V Ñ ¢hal−Zl fÊL«¢a x p¡d¡le Sl¦l£

Type of delivery Regular Express

hÉ¢š²Na J e¡N¢lLa Ä pwœ²¡ñ(Personal

abÉ & 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

f¡a¡-1
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−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).

fÊbj Awn First Part (Given Name)

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)
¢àa£u Awn Second Part (Surname)

8z* ¯hh¡¢qL AhÙÛ¡ () ¢Qq² ¢ce x A¢hh¡¢qa ¢hh¡¢qa

Married
¢hfaÀ£L / ¢hdh¡ a¡m¡LfÊ¡f¹
Marital Status Unmarried Widower/Widow Divorced
Put ( ) 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 Day
Date of Birth Month
Year

f¡a¡-2
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
Number

14z ¢VA¡CHe (k¢c b¡−L) x

- -
Tax Identification
Number (if available)

15z* EµQa¡ x −px¢jx Or C¢’ 16z* dj Ñ 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 () ¢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¡V Ñ ew
_________________
Name of the other country in case of dual citizenship Passport No.

19z* haÑj¡e (h¡wm¡−c−n A¡−hc−el ®r−œ fË−k¡SÉ) (Applicable only when applying in Bangladesh)
¢WL¡e¡ x
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¡ _______________________ ______

l¡Ù¹¡/hÓL/−pƒl________________________
Permanent Village/House Road/Block /Sector

f¡a¡-3
 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

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

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 pÇfL Ñ x
22z* Name Relationship with the applicant

¢WL¡e¡ x
Address

®g¡e/gÉ¡„ eðl C-®jCm ¢WL¡e¡

Phone/Fax Number e-mail Address

f§−h Ñ fÊc¡eLªa f¡p−f¡V Ñ eðl (fÊ−k¡SÉ q−m) x Cp¤Él ÙÛ¡e J a¡¢lM

23z
Previous passport details (if applicable) Place and Date of Issue
f¡p−f¡V Ñ f¢lhaÑ−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
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)

f¡a¡-4
 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)

Receipt/Transaction No.

AwN£L¡l e¡j¡Declaration
( )
n¡M¡ l¢nc ew a¡¢lM
Branch Date

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¡hNÊÙ Û q−u fs−m ¢h−cn ®b−L A¡j¡−L Abh¡ A¡j¡l ®f¡oÉ−L ®c−n
fÊaÉ¡haeÑ
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 jaª É ¤ 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)

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)

Police Verification Report )

f¤¢mn ®i¢l¢g−Lne ¢l−f¡V(Ñ

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

f¡a¡-5
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 pf¤ ¡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 pwkš¤ ² Ll−a q−h
1z plL¡l£, A¡d¡plL¡l£, ü¡ušn¡¢oa J l¡ø¡Ë uaÄ pwÙÛ¡l Ù¡Û u£ LjLÑ a¡Ñ /LjLÑ ¡l£, AhplfË¡ç plL¡l£ Q¡Ll¤ £S£¢h J a¡−cl ¢eilÑ n£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 pjfeÑ Laª (p¡−lä¡lX) ®cl
SeÉ HL¢V glj J AeÉ¡eÉ−cl ®r−œ eae¤ f¡p−f¡−VÑl SeÉ 02 (c¤C) L¢f f§lZLªa f¡p−f¡V Ñ 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−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±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 acd¤ Ä Ñ ®NË−Xl
LjLÑ a¡Ñ 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¡V Ñ 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 z
7z e¡−jl pw¢rçl©−fl f¢lh−a Ñ 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 fË¡ç fch£pjq§ (−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 fl§ −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−§ h Ñ "jaª/jlýj/Late' ®mM¡ k¡−h
e¡ z

A¢g−pl hÉhq¡−ll SeÉFOR

( 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¡V Ñ CpÉ ¤ Ae¤−j¡ceL¡l£ LjÑLaÑ¡l e¡j, BC¢X J ü¡rl

4z Cp¤ÉL«a f¡p−f¡V Ñ eðlx f¡p−f¡V Ñ ¢haleL¡l£

A¢gp¡−ll e¡j, BC¢X J ü¡rl
5z A¡−hceL¡l£l f¡p−f¡V Ñ fÊ¡¢çl ü¡rl J a¡¢lM

f¡a¡-6