CONSULATE GENERAL OF BANGLADESH

211 EAST 43RD STREET, SUITE 502, NEW YORK 10017, USA Print
TEL - (212) 599 6767, (212) 599 6850, (212) 599 1874, FAX - (212) 682 9211
E-MAIL: contact@bdcgny.org, WEB - www.bdcgny.org

Please attach 4 copies of 40mm X

APPLICATION FOR PASSPORT 50mm photograph taken within the
PLEASE FILL IN TWO COPIES OF THIS FORM. PLEASE TYPE OR PRINT IN BLOCK LETTERS. last six months
UNLESS OTHERWISE MENTIONED, PLEASE COMPLETE ALL ITEMS OR WRITE "N/A" (NOT APPLICABLE) ) IF NEEDED. (two copies in each of the forms)

Passport has completed 10 years / will complete 10 years within next 6 months
Pages of passport have been exhausted
Passport has been damaged
Passport has been lost / stolen / destroyed Service Priority Ordinary Urgent

1. Name

1. a. Other name(s) [If applicable]

2. Bangladesh Nationality By Birth By Descent Immigration Other 3. Sex Male Female

4.a. Nationality
4. Name of father

5. Name of mother 5.a. Nationality

6. Name of legal guardian [If applicable] 6.a. Nationality

7. Marital status Single Married Widow/Widower Divorced

8. Name of spouse 8.a. Nationality

9. Please check (X) whose name should appear on passport [In case of married female applicants only. Father Husband
Please provide copy of marriage certificate if you want to insert husband's name in place of father's name]

10. Profession of the applicant

[day-month in words-year]
11. Date of birth [e. g. 26-March-1971] 12. Place of birth (District)

13. Height Meter Centimeter 14. Color of eyes 15. Color of hair

16. Visible distinguishing marks

17. Present address 18. Permanent address in Bangladesh

Street Village/Area/Road:

House/Apt # Post Office

City Thana/Upazila

State Zip District

Home Tel: Cell:

Specimen signature of the applicant (in both the boxes)

[To be affixed to passport]

BDCGNY-PP-01 (01-2006) E This form can be filled electronically. Please visit http://www.bdcgny.org to download a copy. PAGE 1 OF 3
APPLICATION FOR PASSPORT (PAGE 2 OF 3)

19. Endorsement(s) [Complete this section only if you would be endorsing your children in your passport. A maximum of two children below
the age of 12 years can be endorsed in any passport of their parents. ]

19. a. First child 19. b. Second child

Please attach two copies of Please attach two copies of

30mm X 30mm photograph 30mm X 30mm photograph
taken within the last 6 months taken within the last 6 months

Name Name

Date of birth [e. g. 26-Mar-1971] Date of birth [e. g. 26-Mar-1971]

Place of birth (District) Place of birth (District)

Relationship Son Daughter Relationship Son Daughter

20. Declaration - A
[Information on previous passport]
Upon solemn oath, I declare that all information given on this applicaiton are true, correct and complete and I do not possess passport of any other
country or I possess DNC issued by Government of Bangladesh. I understand that I am subject to prosecution if I have given any false information.

I held a Bangladesh passport of the following description: Passport #

Place of issue Date of issue Date of expiry

[e. g. 26-Mar-1971] [e. g. 26-Mar-1971]

I never held a Bangladesh passport of any other description before this application.

Date Signature of the applicant

[e. g. 26-Mar-1971]

21. Declaration - B [Complete this section if you are applying against a lost / stolen / destroyed passport.]
Upon solemn oath, I declare that my passport has been lost /stolen / destroyed on
I have reported this to
[e. g. 26-Mar-1971]
local police. lf this passport comes back to my possession, I will return it to a passport office in Bangladesh or the nearest Bangladesh Mission
abroad.

Date
[e. g. 26-Mar-1971] Signature of the applicant

BDCGNY-PP-01 (01-2006) E This form can be filled electronically. Please visit http://www.bdcgny.org to download a copy. PAGE 2 OF 3
APPLICATION FOR PASSPORT (PAGE 3 OF 3)
22. Attestation [If the passport has been lost / stolen / destroyed , two atttestors holding a valid Bangladesh passport must attest the following] :

I attest that the applicant is known to me for more than two years. To the best of my knowledge and belief, all information given by this applicant
are true, correct and complete and he/she does not possess passport of any other country or he/she possesses DNC issued by Government of
Bangladesh. The applicant has signed the application in my presence.
23. a. First attestor 23. b. Second attestor:

Name Name

Passport # Date of expiry Passport # Date of expiry

[e. g. 26-Mar-1971] [e. g. 26-Mar-1971]
Present Address Present Address

Street Street

House/Apt # House/Apt #

City City

State State

Zip code Zip code

Phone Phone

Signature of the Signature of the

first attestor second attestor

[The attestors must attach photocopy of first seven pages of their passport]

24. a. Signature of the applicant 24. b. Signature of the applicant

[in the presence of the [in the presence of the
first attestor] second attestor]

Date [e. g. 26-Mar-1971] Date [e. g. 26-Mar-1971]

25. a. Money order # 25.b.. Issued by 25.c. Amount ( in US $ )

FOR OFFICIAL USE ONLY.

Receipt # Date Amount ( in US$)

[e. g. 26-Mar-1971]

Mode of Service Mail-In Walk-In Received by Processed by

Passport # Date of issue Date of expiry

[e. g. 26-Mar-1971] [e. g. 26-Mar-1971]

Comments Signature of the issuing authority

Date Date
[e. g. 26-Mar-1971] [e. g. 26-Mar-1971]

BDCGNY-PP-01 (01-2006) E This form can be filled electronically. Please visit http://www.bdcgny.org to download a copy. PAGE 3 OF 3