MYcÖRvZš¿x evsjv‡`k miKvi

ewnivMgb I cvm‡cvU© Awa`ßi

wiBmy¨/Z_¨ cwieZ©b/ms‡kvab Av‡e`b dig
Reissue/Information Alteration/Correction Application Form
digwU cvm‡cv‡U©i †gqv` DËxY©, Z_¨ cwieZ©b/gy`ªYRwbZ fzj ms‡kvab msµvšÍ wel‡q e¨eüZ n‡e|
This form will be used to reissue, to change the information/rectify the printing errors of passport.

 wb‡`©kbv t digwU Bs‡iwR‡Z (CAPITAL LETTER’S) c~iY Kiæb Ges AbyMÖnc~e©K Avcbvi Av‡e`‡bi mv‡_ Dchy³ cÖgvYvw` mshy³ Kiæb|
Instruction : Please fill up the form in English (CAPITAL LETTER’S) and attach relevant documents in favour of your
application.

wefvMxq/ AvÂwjK cvm‡cvU© Awdm/wgk‡bi bvg cvm‡cvU© weZi‡Yi cÖK„wZ

Name of Divisional/Regional Passport Office/Mission Type of delivery
mvaviY Riæwi
Regular Express

Av‡e`bKvixi bvg (evsjvq) wd cÖ`vb msµvšÍ Z_¨

Name of Applicant (In Bangla) Payment of Fees
Av‡e`bKvixi bvg (Bs‡iwR‡Z)
 wdÕi cwigvY ($/USD)
Name of Applicant (in English)
Amount of Fee ($/USD)
 e¨vsK/wgk‡bi bvg
M„nxZ cvm‡cv‡U©i Z_¨ Bank/Mission
Received Passport’s Details
 kvLv
cvm‡cvU© b¤^i Passport No. Bmy¨i ¯’vb Place of Issue
Branch
 iwk` bs
Receipt No.
‡gqv` DËx‡Y©i ZvwiL Date of Expiry Bmy¨i ZvwiL Date of Issue
 ZvwiL
Date

PvwnZ ms‡kvab Expected Correction

cvm‡cv‡U© eZ©gv‡b cÖ`wk©Z Z_¨ cÖZ¨vwkZ cwieZ©b/ms‡kvab

Information on existing passport Expected Change/Correction

ZvwiL
Date

Av‡e`bKvixi/Awffve‡Ki (Av‡e`bKvix AcÖvßeq¯‹ n‡j) ¯^v¶i

Applicant’s/Guardian’s (if the applicant is a minor) Signature