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P. 1
Mr p Applicationform

Mr p Applicationform

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Published by Shabbir Hasan

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Published by: Shabbir Hasan on Jul 01, 2012
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07/01/2012

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f¡a¡-
1
 
NZfÊ S¡a¿ NZfÊ S¡a¿ NZfÊ S¡a¿  NZfÊ S¡a¿»  »»  »£ h¡wm¡−cn plL¡l   £ h¡wm¡−cn plL¡l   £ h¡wm¡−cn plL¡l   £ h¡wm¡−cn plL¡l 
 h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl  h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl  h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl   h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl f¡p−f¡ f¡p−f¡ f¡p−f¡ f¡p−f¡−  −−  −VÑ  VÑ  VÑ  VÑl  l l A¡−hce  A¡−hce  A¡−hce  A¡−hce glj glj glj glj
Passport Application 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 Letter)
 lZ£uz
Except serial number 1 all other serials must be filled in English(Capital Letter).
 
*B’¢mL f¡p−f¡VÑ A¢g−pl e¡j x
________________________________
 *A¡−hc−el fÊ L«¢a x ea¤  e eh¡ue 
Name of RPO Application type New Renew
*A¡−hceL« a f¡p−f¡−VÑ  l fÊ L« ¢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 fÊ L«¢a p¡d¡le Sl¦l£ 
Type of delivery Regular Express
 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*
 
 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 38¢V Arl 
 
 hÉhq¡l Ll¡ k¡−hz
Name of Applicant – Type as you want it to appear in your passport. Maximum 38 characters are allowed.
bj Awn 
 First Part
 ¢àa£u Awn 
 Second Part
 
(
 ¢hxcËx 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
T
he lastpart of the name should appear in second part. Keep a blank space between two parts of the 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»  £/A¢ii¡h−Ll e¡j x
_______________________
 −fn¡ x
___________________
S¡a£ua¡ x
____________
 (fÊ −k¡SÉ q−m)
Spouse’s/Guardian’s Name Profession Nationality
 
(if applicable)
7z*
 
 SeÈÙÛ  ¡e (®cn J −Sm¡) x ®c−nl e¡j
___________________________
−Sm¡l e¡j
______________________
 
Place of Birth Country District
 
8z*
 
 SeÈ a¡¢lM x ¢ce j¡p hvpl 
Date of Birth
Day Month Year
9z*
 
 ¢mwN (¢VL (
) ¢Qq² ¢ce) x f¥l¦o j¢qm¡ AeÉ¡eÉ 
 
Gender (Put (
) in appropriate box) Male Female Others
 A¡−hceL¡l£l HL¢V l¢Pe  R¢h 55 ^ 45 ¢jx¢jx A¡L¡−ll R¢h A¡W¡ ¢c−u  m¡N¡−e¡l fl paÉ¡ue Ll−a  q−h 
 
Affix the photographhere and attest on thephoto
 A¡−hceL¡l£l ¢fa¡l HL¢V l¢Pe R¢h 30 ^25 ¢jx¢jx A¡L¡−ll R¢h  A¡W¡ ¢c−u m¡N¡−e¡l fl  paÉ¡ue Ll−a q−h 
 Affix applicant’sFather’s photographhere and attest on thephoto
 A¡−hceL¡l£l j¡a¡HL¢V l¢Pe R¢h 30 ^25 ¢jx¢jx A¡L¡−ll R¢h  A¡W¡ ¢c−u m¡N¡−e¡l fl  paÉ¡ue Ll−a q−h 
 Affix applicant’sMother’s photographhere and attest on thephoto
 −Lhmj¡œ Af¡Êçhuú A¡−hceL¡l£l −r−œ  Ef−l¡š² R¢hàu BhnÉLz
 
 ¢X.BC.¢f - 1
(
 ¢he¡j¨ −mÉ fÊ ¡fÉ)
 
 
f¡a¡-
2
 10
[[
z
 
 SeÈ pecfœ ew (k¢c b¡−L 
)
x
B
irth Identification Number
 
(if available)
11z S¡a£u f¢lQuf−œl ew (k¢c b¡−L 
)
x
National Identification Number(if available)
12z
 
 ¢VA¡CHe (k¢c b¡−L) x
 Tax Identification Number (if available)
13z*EµQa¡ x −px¢jx C¢’
Height cm inch
14z*
 
 ¯hh¡¢qL AhÙÛ  ¡ (¢VL (
) ¢Qq² ¢ce) x A¢hh¡¢qa ¢hh¡¢qa ¢hfaÀ  £L / ¢hdh¡ a¡m¡LfÊ ¡f¹
 
Marital Status Unmarried Married Widower/Widow DivorcedPut
(
)
in appropriate box
 15z*
 
 −fn¡ x
_______________________________________________________________________________
 Profession
16z*
 
 haÑ  j¡e ¢WL¡e¡ x
 
 ¡j / h¡p¡ ew 
_____________________________
 l¡Ù¹ ¡/hÓ L ew 
_________________________
 
Present Village/House No. Road/Block No.Address
b¡e¡ 
___________________________________
 X¡LOl 
___________________________
 
Police Station Post Office
 −Sm¡ 
__________________________________
 −f¡ØV®L¡X
_________________________
 
District Post Code
 Øq¡u£ ¢WL¡e¡ J haÑ  j¡e ¢WL¡e¡ HLC q−m ¢VL (
)¢Qq² ¢ce 
Put (
)
if Permanent Address is same as Present Address
 17z*
 
 ÙÛ  ¡u£ ¢WL¡e¡ x
 
 ¡j / h¡p¡ ew 
_____________________________
 l¡Ù¹ ¡/hÓ L ew 
_________________________
 
Permanent Village/House No. Road/Block No.Address
b¡e¡ 
___________________________________
 X¡LOl 
___________________________
 
Police Station Post Office
 −Sm¡ 
__________________________________
 −f¡ØV−L¡X
_________________________
 
District Post Code
18z
 
 Sl¦l£ ®k¡N¡−k¡−Nl SeÉ ®g¡e eðl x A¢gp 
_______________________
 −j¡h¡Cm eðl 
_______________________
 
Emergency contact numbers Office Mobile No.
  h¡p¡ 
________________________
C®jCm ¢WL¡e¡ 
______________________Residence email
19z*h¡wm¡−cn£ e¡N¢lL−aÆ l p§  œ x S¸jp§  −œ hwnp§  −œ A¢ih¡pe ®cn£uLlZ p¤  −œ  (¢VL (
) ¢Qq² ¢ce)
by birth by descent Migration NaturalizationType of Citizenship
 ¯hh¡¢qLp§  −œ 
 
 AeÉ¡eÉ 
,
 E−õM Ll¦e 
 Put
(
)
in appropriate box by marriage Others, please specify _________________________
 
20z
 
®~  àa e¡N¢lL q−m e¡N¢lLaÆ
 
 c¡eL¡l£ ®c−nl e¡j x
_________________________
f¡p−f¡VÑ ew 
_________________
 
Name of the other country in case of dual citizenship Passport No.
- -
 
f¡a¡-
 3
 21z*f¡p−f¡−VÑ  l SeÉ ¢gp Sj¡ pwœ¦¡¿¹abÉ¡hm£ (−k abÉ…−m¡ fÊ −u¡SÉ q−h) x
Fees Payment Information
 hÉ¡wL 
 ____________________________ 
n¡M¡ 
 ______________________ 
 Sj¡Lª a ¢g Hl f¢lj¡e 
 ___________
Name of the Bank Branch Amount deposited
 l¢nc ew 
 __________________________________ 
 a¡¢lM
 _______________________ 
 
Receipt/Transaction No. Date
22z
 
f§  −hÑ  c¡eLª a f¡p−f¡−VÑ  l ¢hhlZ (fÊ −k¡SÉ q−m) x
Previous passport details (if applicable)
f¡p−f¡VÑ eðl 
 
 _____________________________ 
Cp¤  Él ÙÛ  ¡e J a¡¢lM
 
 ________________________________ 
Passport No. Place and Date of Issue
f¡p−f¡VÑ f¢lhaÑ  −el L¡lZ 
 
(
 ¢VL (
) ¢Qq² ¢ce) x q¡l¡−e¡ hÉhq¡−ll Ae¤ fk¤  š² −ju¡c Eš£ZÑ 
 Reason for re apply Lost Unusable Expired
Put
(
)
in appropriate box
 
 ¢S¢X eðl (fÊ −k¡SÉ ®r−œ)
 _________________________________________ 
 a¡¢lM
 _____________________
 
GD No. (if applicable) Date
b¡e¡l e¡j (−k b¡e¡u ¢S¢X Ll¡ q−u−R )
 __________________________________________________________
Name of the Police Station
(wet `ªt eZ©  gvb cvm‡cvU© bevqb/weKí cvm‡cv‡U©  i †¶‡ÎI wgK bs 22 cÖ ‡hvR¨ n‡e|
Serial 22 will also be applicable forrenewal of existing passport/for issuing duplicate passport.)
 AwN£L¡l e¡j AwN£L¡l e¡j AwN£L¡l e¡j AwN£L¡l e¡j¡  ¡¡  ¡ 
1z A¡¢j nfb L−l hm¢R ®k A¡−hcef−œ  cš ph abÉ paÉ Hhw ®L¡e ¢jbÉ¡ abÉ ¢c−u b¡L−m A¡¢j A¡Ceax cäe£u qhz2z A¡¢j A¡−l¡  ¢a‘¡ Ll¢R A¡¢j/A¡j¡l p¿¹ ¡e h¡ ®f¡oÉ, ®k ®L¡e L¡l−Z Ai¡hNÊ ÙÛ q−u fs−m ¢h−cn ®b−L A¡j¡−L Abh¡ A¡j¡l ®f¡oÉ−L  ®c−n fÊ aÉ¡haÑ  e Ll¡l ®r−œ k¡ha£u MlQ f¢l−n¡−d h¡dÉ b¡Lh Hhw ¢h−c−n A¡j¡l/¢Lwh¡ A¡j¡l p¿¹¡e h¡ ®f¡−oÉl jª aɤ 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)
 paÉ¡ue  paÉ¡ue  paÉ¡ue  paÉ¡ue 
(B−hceL¡l£ S¡a£u f¢lQufœ d¡l£ e¡ q−m) A¡j¡l ‘¡e J ¢hnÄ ¡pj−a Ef−l h¢ZÑ  a abÉ paÉ Hhw 
 ____________________________________ 
(B−hceL¡l£)
 ________
 hvpl  k¡hv A¡j¡l f¢l¢Qaz ¢a¢e A¡j¡l pjȤ  −M A¡−hcef−œ ü¡rl / ¢VfpC fË c¡e L−l−Rez paÉ¡ueL¡l£l A¡h¡¢pL ¢WL¡e¡ x
 ___________________________ 
__________________ 
 _______________________________________________ 
paÉ¡ueL¡l£l e¡j J ü¡rl  a¡¢lM x
 ______________ 
 f¡p−f¡VÑ  /S¡a£u f¢lQu fœ ew 
 _____________________ 
  −V¢m−g¡e eðl (k¢c b¡−L)
 _______________________________ 
(p£m ®j¡ql)

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