One (1) copy

CONSULATE GENERAL OF BANGLADESH, MIAMI of 02 inch X

760 NW 107th Avenue, Suite-320, Miami, FL-33172 02 inch
E-mail: mission.florida@mofa.gov.bd; Website: https://florida.mofa.gov.bd Photograph

APPLICATION FOR ENDORSEMENT OF ‘NO VISA REQUIRED’ FOR TRAVEL TO BANGLADESH

PLEASE FILL IN OR TYPE IN BLOCK LETTERS

1. Name
2. Date of Birth (e.g., 26-Mar-1971) 3. Place of Birth
4. Nationality at birth 5. Present nationality 6. Profession
7. US Passport no. 8. Date of issue 9. Date of expiry
10. Sex Male Female 11. Marital status Single Married Widow/Widower Divorced
12. Name of spouse Nationality: Bangladesh Other (please specify)
13. Name of father Nationality: Bangladesh Other (please specify)
14. Name of mother Nationality: Bangladesh Other (please specify)
15. Present address and contact details
Street House/Apt. City ZIP code
State Cell no.
16. Purpose of visit Tourism Visit relatives Other (please specify)
17. In case of reissue of NVR, please provide the following information:
a) Previous NVR issued by Bangladesh Embassy/Consulate General, Washington DC/New York/Los Angeles/Miami
Others (please specify)
b) Previous US passport no. c) NVR seal no. d) Date of issue
of NVR
18. DECLARATION
I declare that I have examined the information on this Signature of the applicant
form. To the best of my knowledge and belief, the (in case of a minor child,
information on this form is true, correct and complete. parents may sign on behalf)

19. a) Money Order/Bank Draft no. b) Issued by: c) Amount in US$: 50.00

FOR OFFICIAL USE ONLY (Do not write below this line)

Receipt no: _____________________________________ Date: ___________________ Amount (US$): 50.00

Mode of service: Mail-In Walk-In
Received by: _____________________________________ Processed by: ____________________________________
Issue no.: NVR/2022/________________________
Comments:

Signature of the issuing authority