X.BC.

f glj - 1 (hejm ff)

AhceLll HLV lPe
55 ^ 45 jxjx ALll
Rh AW cu mNel fl
paue Lla qh

NZfSa hwmcn plLl

hqlNje J fpfV Adcl

jne lXhm fpfV Ahce glj

Affix the photograph

here and attest on the
photo

Machine Readable Passport Application Form

AhceLll fal
HLV lPe 30 ^ 25
jxjx ALll Rh
AW cu mNel fl
paue Lla qh

AhceLll jal
HLV lPe 30 ^ 25
jxjx ALll Rh
AW cu mNel
fl paue Lla qh

Affix applicants
Fathers photograph
here and attest on the
photo

Affix applicants
Mothers photograph
here and attest on the
photo

Lhmj 15 hvpll eQ Afhu

AhceLll r Efl Rhu fuSe z
Ahce fV flZ Lll fh AeNqfhL no fu hZa pdle ecnepjq paLal pqa fW Llez
Please read carefully the General Instructions at the last page before filling the form.
alL (*) Qqa jL ew m Ahn flZuz
Serial numbers marked with star (*) marks must be filled in.
jL ew 1 haa Aee jL CwlSa (Capital Letters) flZu z
Except serial number 1, all other serials must be filled in English (Capital Letters).

* BmL fpfV Agp/hwmcn jne x

* Ahcel fLa x

eae

fex fce

Name of RPO / Bangladesh Mission

Application type

New

Reissue

* AhceLa fpfVl fLa x

Type of passport applied for

* fpfV halZl fLa x

Type of delivery

pdle

Agpum

LVeaL

Ordinary

Official

Diplomatic

pdle

Sll

Regular

Express

hNa J eNlLa pw ab (Personal & Citizenship Details)

1z

AhceLll ej (hwmu) x ________________________________________________________________

Name of Applicant (in Bengali)

2z*

AhceLll ej x _______________________________________________________________________

3z*

Name of Applicant
BhceLll ej - Afe fpfV ej kih cMa Qe pih VCf Lle z phQ 48V Arl hhql Ll khz
Name of Applicant Type as you want it to appear in your passport. Maximum 48 characters are allowed.

(ejl nown 2u Awn mMa qh Hhw 1j Awn HLdL Awn bLm fa Awnl jTMe 1V Ol ne lM flZ Lla qh z The last
part of the name should appear in second part. Keep a blank space between two parts of the name).
fbj Awn First Part (Given Name)

au Awn Second Part (Surname)

4z*

fal ej x _______________________________ fn x ___________________ Saua x _____________

Fathers Name

5z*

Nationality

jal ej x ________________________________ fn x ___________________Saua x ____________

Mothers Name

6z

Profession

j/ -l ej x ________________
(fkS qm) Spouses Name

Profession

Nationality

_______fn x ___________________ Saua x ____________

Profession

Nationality

(if applicable)

7z

AiihLl ej x _____________
(fkS qm) Guardians Name

__________fn x ___________________ Saua x ____________

Profession

(if applicable)

fa-1

Nationality

8z*
9z*

hhqL Ah (3) Qq ce x

Ahhqa

hhqa

hfaL / hdh

amLff

Marital Status
Put (3) in appropriate box

Unmarried

Married

Widower/Widow

Divorced

fn x _____________________________________________________________________________ _
Profession

Agpum fpfVl r x (In case of Official Passport)

Agpl ej x ____________________________________________ Ahpl Nqel alM x ________________
Name of the Office

10z*
11z*
12z*
13z*

Date of Retirement

See (cn J Sm) x

cnl ej ___________________________ Sml ej ______________________

Place of Birth

Country

District

Se alM x

ce

Date of Birth

Day

jp

hvpl

Month

Year

mwN (3) Qq ce x

flo

jqm

Aee

Gender (3) in appropriate box

Male

Female

Others

Se pecf ew x
Birth Identification

Number
Or Abh

Sau flQufl ew x
National Identification
Number

14z

VACHe (kc bL) x

Tax Identification
Number (if available)

15z*
17z*

EQa x

pxjx

Height

cm

hwmcn eNlLal p x
(VL (3) Qq ce)
Type of Citizenship
Put (3) in appropriate box

18z

Or
Abh
Sjp

hwnp

by birth

by descent

16z*

Religion

Aihpe
Migration

cnuLlZ p
Naturalization

hhqLp

Aee, EM Lle

by marriage

Others, please specify __________________ _______

~a eNlL qm eNlLa fceLl cnl ej x _________________________ fpfV ew _________________

Name of the other country in case of dual citizenship

19z*

dj

inch

haje WLe x
Present
Address

Passport No.

(hwmcn Ahcel r fkS) (Applicable only when applying in Bangladesh)

Nj / hp _____________________ ________ l/hL/pl _______________ ______
Village/House

Road/Block /Sector

be ___________________________________ XLOl ___________________________

Police Station

Post Office

Sm __________________________________ fVLX
District

Post Code

ge el

C-jCm WLe

Contact Number

e-mail Address

qu WLe J haje WLe HLC qm VL (3)Qq ce

Put (3) if Permanent Address is same as Present Address

20z*

u WLe x

Nj/hp _______________________

Permanent
Address

Village/House

______ l/hL/pl________________________
Road/Block /Sector

be ___________________________________ XLOl ___________________________

Police Station

Post Office

Sm __________________________________ fVLX _________________________

District

Post Code

ge el

C-jCm WLe

Contact Number

e-mail Address

fa-2

21z

hcnL WLe x (hcnL WLe Lhmj hwmcn jne Ahcel r fkS)

Overseas
Address

(Applicable only when applying in Bangladesh Missions)

WLe
Address

22z*

cn

ge/g el

C-jCm WLe

Country

Phone/Fax Number

e-mail Address

Sll fuSe kNkNl Se hl hhlZ x

(Emergency contact persons details)
ej x

AhceLll pb pfL x

Name

Relationship with the applicant

WLe x
Address

23z

24z

25z*

ge/g el

C-jCm WLe

Phone/Fax Number

e-mail Address

fh fceLa fpfV el (fkS qm) x

Cpl e J alM

Previous passport details (if applicable)

Place and Date of Issue

fpfV flhael LlZ (3) Qq ce x

flhae

Reason for re apply

Put (3) in appropriate box

Conversion

hhqll Aefk
Unusable

juc EZ

qle

Expired

Lost

SX el (fkS r)

bel ej

alM

GD No. (if applicable)

Name of the Police Station

Date

Ahce fl pb pwk cmmc x

(Enclosures attached with the application form)
Sau flQufl gVLf

Se ehe pecl gVLf

(Copy of National ID)

(Copy of Birth RegistrationCertificate)

plLl Acnl (SJ) gVLf

(fkS r) (Copy of Government Order)

Rsfl (HeJp) Lf

hcje fpfVl gVLf

VLeLm pecl gVLf

(fkS r)(Copy of NOC)

(fkS r)(Copy of Previous Passport)

(fkS r)(Copy of Technical Certificates)

VACHe pecl gVLf

fXHp/Ahpll alMl fjef

(fkS r)
(Copy of TIN Certificate)

(fkS r) (PDS/Proof of Retirement Date)

fpfVl Se gp Sj pw abhm (k abm fkS qh) x Payment Information

hwL/hwmcn jne

SjLa g Hl flje (VL/jLe Xml )

Name of the Bank/Bangladesh Mission

Amount deposited (US$ in case of Bangladesh Missions)

nM

lnc ew

alM

Branch

Receipt/Transaction No.

Date

AwNLl ej (Declaration)
1z

Aj nfb Ll hmR k Ahcef fc ph ab pa Hhw Le jb ab cu bLm Aj ACeax ceu qhz

2z

Aj Al fa LlR Aj/Ajl pe h fo, k Le LlZ AihN qu fsm hcn bL AjL Abh Ajl foL cn fahae

Lll r khau MlQ flnd hd bLh Hhw hcn Ajl/Ajl pe h fol ja OVm jlcql flhqe MlQ Ajl hd EldLl/Ajl LR
bL AcukN qhz

alM x _____________________

AhceLll/AiihLl (AhceLl Af hu qm)

rl h VfpC (Aefeu Lma)

fa-3

faue (Certification)
Ajl e J hnpja Efl hZa ab pa Hhw BhceLl

hvpl khv Ajl flQaz ae Ajl pjM Ahcef rl /

VfpC fce LlRez

paueLll AhpL WLe x
paueLll ej J rl
fpfV/Sau flQu f ew

alM x _____________

Vmge el (kc bL)

(pm jql)

fmn ilgLne lfV(Police Verification Report)

fmn ilgLne el x _______________________________________________
AhceLll abl paa kQC x

pWL

alM x_____________________

pWL eu

pWL e qm LlZ (hwmcn eNlL ee/pSf/ jjmde/ WLe pWL eu/ Aee LlZ) x

_____________________________

________________________

_____________________________

fahce CpLl Agpll rl

pfliCSw Agpll rl

fahce farlLl Agpll rl

(fmn BCX J pm)

(fmn BCX J pm)

(fmn BCX J pm)

ecne (General Instruction)

AhceLlL ejmMa cmmc Bhcef AhnC pwk Lla qh
1z plLl, AdplLl, unoa J lua pwl u LjLa/LjLl, Ahplf plLl QLlSh J acl eilnm /j Hhw plLl
QLlShl 15 (fel) hvpll Lj hupl pe, 5 (fyQ)/10 (cn) hvpll Aa, pjfeLa (pllX) cl Se HLV glj J Aeecl r eae
fpfVl Se 02 (cC) Lf flZLa fpfV glj cMm Lla qh z
2z Afhu (15 hRll Lj) AhceLll r AhceLll fa J jal HLV Ll lPe Rh (30 ^ 25 jxjx) Rh AW cu mNel fl paue
Lla qhz
3z Sau flQuf Abh Se ehe pec Hhw fkS r fpL VLeLm pecpjql (kje Xl, Ceul, XCil Cac) paua gVLfz
4z k pLm hNZ fpfVl Ahcef J Rh faue J paue Lla flhe- pwpc pcp, pV Lflnel jul, XfV jul J LEpmlNZ,
NSVX LjLa, fhmL hnhcmul nrL, EfSm flocl Qulje J iCp Qulje, CEeue flocl Qulje, flpil jul J fl
LEpmlNZ, hplLl hnhcmul AdfL, hplLl LmSl Adr, hplLl EQ hcmul fde nrL, Sau ceL fLl pfcL, eVl
fhmL J AdplLl/unpa/lu pwl Sau hae ml 7j J acd NXl LjLaNZ z
5z fkS r fpL S J (GO)/ He J p (NOC) cMm Lla qh z
6z LVeaL fpfV mil kN AhceLlNZL flZLa glj J pwkpjq fll jZmu Sj ca qh z
7z ejl pwrlfl flha fZlf ( kje-jx/MD. Hl m jqjc/MOHAMMAD) mM heu z nrNa h QLlp f fchpjq (kje
Xl, Ceul, Xl, fHCQX Cac) ejl Awn qph flNZa qh e z gljl jL ew 3 flZl r, HLdL Awn bLm fa Awnl jTMe
1V Ol ne lM flZ Lla qh z AhceLll fa, ja, j/ ja qmJ, al/acl ejl fh "ja/jlj/Late' mM kh e z

Agpl hhqll Se (FOR OFFICIAL USE ONLY)

1z

ab pwNqLl (AflVl) Hl ej, BCX J rl

2z

Ahce NqeLl Agpll ej, BCX J rl

3z

fpfV Cp AejceLl LjLal ej, BCX J rl

4z

CpLa fpfV elx

5z

AhceLll fpfV fl rl J alM

fpfV haleLl Agpll ej, BCX J rl

fa-4