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 Dhaka

Name of RPO / Bangladesh Mission

* AhceLa fpfVl fLa x

Type of passport applied for

pdle

Ordinary

* fpfV halZl fLa x

pdle

Type of delivery

Regular

* Ahcel fLa x

eae

Application type

New

Agpum

LVeaL

Official

Diplomatic

fex fce
Reissue

Sll
Express

hNa J eNlLa pw ab (Personal & Citizenship Details)

1z

AhceLll ej (hwmu) x ________________________________________________________________

Name of Applicant (in Bengali)

2z*

Md. Abdur Rahman

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)

M D .

A B D U R

au Awn Second Part (Surname)

R A H M A N
4z*

PASSED AWAY Saua x _____________

BASAI SARDER
fal ej x _______________________________
fn x ___________________
BANGLADESHI

Fathers Name

5z*

Profession

PASSED AWAY
MANSURA BEGUM
jal ej x ________________________________
fn x ___________________Saua
x ____________
BANGLADESHI

Mothers Name

6z

Nationality

Profession

MRS. NAZMA RAHMAN

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

Nationality

HOUSRWIFE
_______fn x ___________________
Saua x ____________
BANGLADESHI

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

Marital Status
Put (3) in appropriate box

Unmarried

hhqa

Married

hfaL / hdh

amLff

Widower/Widow

Divorced

fn x PRIVATE
_____________________________________________________________________________
_
SERVICE
Profession

Agpum fpfVl r x (In case of Official Passport)

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

10z*
11z*

Date of Retirement

See (cn J Sm) x

BANGLADESH
MADARIPUR
cnl ej ___________________________
Sml ej ______________________

Place of Birth

Country

Se alM x

3 1

Date of Birth

12z*

District

ce

mwN (3) Qq ce x

Gender (3) in appropriate box

13z*

1 2

Day

jp

1 9 4 6

Month

hvpl
Year

flo

jqm

Aee

Male

Female

Others

Se pecf ew x
Birth Identification
Number

Or Abh

Sau flQufl ew x

1 9 4 6 2 6 9 2 6 1 9 0 0 0 0 0 9

National Identification
Number

14z

VACHe (kc bL) x

Tax Identification
Number (if available)

15z*

EQa x
Height

17z*

1 6 0

pxjx
cm

hwmcn eNlLal p x
(VL (3) Qq ce)

Or
Abh
Sjp

16z*

ISLAM

Religion

hwnp

Aihpe

by descent

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

by birth

Type of Citizenship
Put (3) in appropriate box

18z

Passport No.

haje WLe x

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

Present
Address

Nj / hp _____________________ ________ l/hL/pl ROAD-73

_______________ ______
Village/House

Road/Block /Sector

GULSHAN
GULSHAN
be ___________________________________
XLOl ___________________________

Police Station

Post Office

Sm

fVLX

DHAKA
__________________________________

District

ge el

1212

Post Code

C-jCm WLe

01757386432

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

HOUSE-26
Nj/hp APT-B3,
_______________________

Permanent
Address

Village/House

ROAD-6
______ l/hL/pl________________________

Road/Block /Sector

DHANMONDI
NEW MARKET
be ___________________________________
XLOl ___________________________

Police Station

Post Office

DHAKA
1205
Sm __________________________________
fVLX _________________________

District

ge el

Post Code

C-jCm WLe

01757386432

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 (In Bangladesh)

(Emergency contact persons details)
ej x SHILA FARHEEN

AhceLll pb pfL x DAUGHTER

Name

Relationship with the applicant

WLe x Vill/House
Address
PS

23z

Apt.-102, Concord Splendour, House-NE-D-2

GULSHAN

Road/Block/Sector

PO: GULSHAN

ge/g el 01713041383

C-jCm WLe

Phone/Fax Number

e-mail Address

fh fceLa fpfV el (fkS qm) x

B 1076524

Cpl e J alM

Previous passport details (if applicable)

fpfV flhael LlZ (3) Qq ce x

flhae

hhqll Aefk

Conversion

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)

hcje fpfVl gVLf

VLeLm pecl gVLf

(fkS r)(Copy of Previous Passport)

(fkS r)(Copy of Technical Certificates)

Rsfl (HeJp) Lf
(fkS r)(Copy of NOC)

25z*

June 4, 2008

Place and Date of Issue

Reason for re apply

Put (3) in appropriate box

24z

District:

ROAD-73
DHAKA

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

June 14, 2012

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