X.BC.

f glj - 1 (hejm ff)

AhceLll HLV lPe

55 ^ 45 jxjx ALll AhceLll fal AhceLll jal
Rh AW cu mNel fl NZfSa hwmcn plLl HLV lPe 30 ^ 25
jxjx ALll Rh
HLV lPe 30 ^ 25
jxjx ALll Rh
paue Lla qh hqlNje J fpfV Adcl AW cu mNel fl AW cu mNel
paue Lla qh fl paue Lla qh
Affix the photograph jne lXhm fpfV Ahce glj Affix applicants
Fathers photograph
Affix applicants
Mothers 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 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 Dhaka * Ahcel fLa x eae fex fce
Name of RPO / Bangladesh Mission Application type New Reissue

* AhceLa fpfVl fLa x pdle Agpum LVeaL

Type of passport applied for Ordinary Official Diplomatic

* fpfV halZl fLa x pdle Sll

Type of delivery Regular Express

hNa J eNlLa pw ab (Personal & Citizenship Details)

1z AhceLll ej (hwmu) x ________________________________________________________________

Name of Applicant (in Bengali)
2z* MRINAL KANTI ROY
AhceLll ej x _______________________________________________________________________
Name of Applicant
3z* 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)
M R I N A L K A N T I

au Awn Second Part (Surname)

R O Y

4z* MOHESH CHANDRA ROY fn x ___________________

fal ej x _______________________________ FARMER Saua x _____________
BANGLADESHI
Fathers Name Profession Nationality

5z* SONKORI RANI ROY

jal ej x ________________________________ HOUSEWIFE
fn x ___________________Saua x ____________
BANGLADESHI

Mothers Name Profession Nationality

6z j/ -l ej x ________________ _______fn x ___________________ Saua x ____________

(fkS qm) Spouses Name Profession Nationality
(if applicable)

7z AiihLl ej x _____________ __________fn x ___________________ Saua x ____________

(fkS qm) Guardians Name Profession Nationality
(if applicable)

fa-1
8z* hhqL Ah (3) Qq ce x Ahhqa hhqa hfaL / hdh amLff
Marital Status Unmarried Married Widower/Widow Divorced
Put (3) in appropriate box
9z* fn x GOVERNMENT
_____________________________________________________________________________
JOB _
Profession
Agpum fpfVl r x (In case of Official Passport)
Agpl ej x ____________________________________________
BANGLADESH FILM ARCHIVE Ahpl Nqel alM x ________________
Name of the Office Date of Retirement
10z* See (cn J Sm) x cnl ej ___________________________
BANGLADESH Sml ej ______________________
NILPHAMARI
Place of Birth Country District

11z* Se alM x ce jp hvpl

Date of Birth 1 1 Day 0 9 Month 1 9 8 4 Year
12z* mwN (3) Qq ce x flo jqm Aee
Gender (3) in appropriate box Male Female Others
13z* Se pecf ew x
Birth Identification
Number
Or Abh
Sau flQufl ew x
National Identification 1 9 8 4 7 3 1 6 4 8 8 3 6 1 8 4 5
Number

14z VACHe (kc bL) x - -

Tax Identification
Number (if available)
HINDU
15z* EQa x
Height
1 6 1 pxjx
cm
Or
Abh
C
inch
16z* dj
Religion
x

17z* hwmcn eNlLal p x Sjp hwnp Aihpe cnuLlZ p

(VL (3) Qq ce) by birth by descent Migration Naturalization
Type of Citizenship hhqLp Aee, EM Lle
Put (3) in appropriate box by marriage Others, please specify __________________ _______
18z ~a eNlL qm eNlLa fceLl cnl ej x _________________________ fpfV ew _________________
Name of the other country in case of dual citizenship Passport No.
19z* haje WLe x (hwmcn Ahcel r fkS) (Applicable only when applying in Bangladesh)
Present
Address _____________________ ________ l/hL/pl ESKATAN
Nj / hp 33 GARDEN
_______________ ______
Village/House Road/Block /Sector
be ___________________________________
RAMNA XLOl ___________________________
RAMNA

Police Station Post Office

Sm DHAKA
__________________________________ fVLX 1000
District Post Code
ge el 01719205945 C-jCm WLe mrinal.eee@gmail.com
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 JOYCHONDI
_______________________ ______ l/hL/pl________________________
Permanent Village/House Road/Block /Sector
Address be ___________________________________
SADAR XLOl ___________________________
DARYANI
Police Station Post Office
Sm __________________________________
NILPHAMARI fVLX _________________________
5300
District Post Code
ge el 01712987743 C-jCm WLe
Contact Number e-mail Address
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21z hcnL WLe x (hcnL WLe Lhmj hwmcn jne Ahcel r fkS)
Overseas (Applicable only when applying in Bangladesh Missions)
Address
WLe
Address

cn ge/g el C-jCm WLe

Country Phone/Fax Number e-mail Address

22z* Sll fuSe kNkNl Se hl hhlZ x (In Bangladesh)

(Emergency contact persons details)
ej x PROMOTH CHANDRA ROY AhceLll pb pfL x BROTHER
Name Relationship with the applicant
WLe x Vill/House JOYCHONDI Road/Block/Sector
Address
PS SADAR PO: DARYANI District: NILPHAMARI
ge/g el 01712987743 C-jCm WLe
Phone/Fax Number e-mail Address

23z 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 hhqll Aefk juc EZ qle

Reason for re apply Conversion Unusable Expired Lost
Put (3) in appropriate box

SX el (fkS r) bel ej alM

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

24z 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) (fkS r) (PDS/Proof of Retirement Date)
(Copy of TIN Certificate)

25z* 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

June 03, 2013

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 01 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 _______________________________________________ alM x_____________________

AhceLll abl paa kQC x

pWL 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 fpfV haleLl Agpll ej, BCX J rl

5z AhceLll fpfV fl rl J alM

fa-4