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High Commission for Bangladesh, Canada

340 Albert Street, Suite:1250, Ottawa, Ontario, K1R 7Y6, Canada Tel:(613)-236-0138-39 Fax:(613)-567-3213 E-mail: Web: Please attach 1 copy of 40 mm X 50 mm photograph taken within the last six months Please provide Four more copies of same size photograph


Service Priority: Why do you need Passport : Passport has expired or will expire within next 6 months Pages of passport have been exhausted Passport or its part has been damaged Passport has been lost or stolen (Police Report is Enclosed)



1. Name: 2. Name: (as it should appear in the passport) 3. Bangladesh Nationality: 4. Date of birth: 6. Height: 8. Color of eyes: 10. Sex: Male Female Meter By Birth By Descent [day-month-year] Centimeter 7. Profession: 9. Color of hair: 11. Marital status: Single Married Widow/Widower Divorced Immigration Other (Specify)

5. Place of birth (District):

12. Visible distinguishing marks (if any): 13. Fathers Name: 15. Mothers Name: 17. Spouses Name: 14. Fathers Nationality: 16. Mothers Nationality: 18. Spouses Nationality: Father Husband

19. Please check whose name should appear on passport [In case of married female applicants only]

20. Present address

Street: Apt # : City : Province: Postal Code : Tel : Cell:

21. Permanent address in Bangladesh

Village/Area/Road: House/Apt # : Post Office : Thana/Upazila: District : Tel (if any):

Please Sign in the boxes below. Signature of the Applicant to be affixed in the passport. (Signature on Both)


23. Particulars of the Previous Passport:

Passport No: Date of Expiry:

_Place of issue:

_Date of issue: [day- month - year]

[day-month - year]

24. Method of Payment Issued by:

Bank Draft / Money Order No: Amount (C$):


[day- month - year]

Declaration: I declare on solemn affirmation as under: I am a citizen of Bangladesh and have never lost it. I have not been refused passport facilities. All previous passports granted to me have been surrendered other than the passport / travel document mentioned below which is being attached herewith. I further declare that I have not submitted any other application for passport /travel document to any Bangladesh authorities at home or abroad since the attached passport or travel document issued to me. I or my legal heir will be responsible to pay for the cost of return, for myself and my dependants journey to Bangladesh, in case of compulsory deportation or unfortunate death. To the best of my knowledge and belief the information given in this application is correct. I am fully aware that by making a statement that is not true, I will render myself liable to prosecution under the law.

Signature of the Applicant: Date: Place:

Full Name:

Office Use Only : Remarks: Serial No: Date of issue: Amount(C$) Passport No: Exp Date: Receipt no:

Signature of the issuing officer:


This Page is to be filled-in and submitted only in case the passport has been lost / stolen.
I have already informed local police about the loss of my passport: Ref. Number: Date: Name of Police Station:

The passport as per detail given below has been lost. In the event of its coming again into my possession, I undertake to return it to the Passport Office in Bangladesh or the nearest Bangladesh Mission abroad. Particulars of the Previous Passport:

Passport No: Date of Expiry:

Place of issue:

_Date of issue: [day- month - year]

_[day-month - year]

Signature of the Applicant: Date: Place: Full Name: ATTESTATION :

To be attested by 2 (two) persons holding valid Bangladeshi passports (Copies of which should be attached with the application)

CAUTION: Attention of the Attesters / Guarantors is drawn to the fact that by attesting any statement contained in this application that is not true s/he will render her/himself liable to prosecution under the law. I, the undersigned, a citizen of Bangladesh, hereby declare that: The applicant Ms / Mr: _is personally known to me for years.

She/he is a Bangladeshi and she/ he has signed /affirmed thumb impression on this form in my presence. To the best of my knowledge and belief, the information given in the application is correct and true. The photograph on the reverse bears her/ his likeliness. Signature: Guarantor- II

Signature: Guarantor- I

Name: Address: City : Tel : _Province: Cell: Postal Code :

Name: Address: City : Tel : Bangladeshi Passport No: Place of Issue: Exp Date: Date of Issue: Exp Date: _Province: _Cell: Postal Code :

Bangladeshi Passport No: Place of Issue: Date of Issue: