Applicant'sPhotographMeasuring

45 mm x35mm

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Government of the People's Republic of Bangladesh

Department of Immigration & Passports

D. I. P Form-4(Free of cost)

Machine Readable Visa Application Form

• This Form Should Be Filled Up In 'Capital Letters'. Put (vi) In Appropriate Box.• Please Go Through The General Instructions Before Filling Up The Visa From.

• Name of Office/ Bangladesh Mission :

PERSONAL DETAILS

Ol. Full Name(as in the passport)

~~~_II_~_-First! Given Name (S) Last! Surname

02. Permanent address:

Contact no: E-mail:

03. Address in Bangladesh: -----------------------------

Contact no: _ E-mail:

04. Date of Birth: / / 05. Sex: Male D Female D Others DDDI MM/YYYY

06. Place of Birth: 1 07 ..Present Nationality: 1 --'1

08. Nationality at Birth: 1 09. Occupation: 1'- ----'1

10. Marital Status Unmarried D Married D WidowerlWidow D Divorced DTRAVEL DOCUMENT DETAILS

12. Type of Passport 1'------------11. Passport No:

13. Place ofIssue:

14. Date of issue: 15. Date of Expiry: _---1.__ --'- _DDI MM I YYYY DDI M M I YYYY

\16. Date of last visit to Bangladesh: I

DDI M M I YYYY

17. Last Visa No: ~of Issue:----------~ DDI M M I YYYY

. ~I 20. Date of Expiry: /L-_~/ _- D DIM M I YYYY

19. Place ofIssue:

PAYMENT DETAILS21. Name of the Bank and Branch: _

22. Cheque/ Bank Transfer/ Chalanl Scroll No: _

23. Amount deposited(Taka/ US$) D DI M M I YYYY

1........ 1 24. Date:

NEW VISA

25. Purpose of Visit: DTourisU EmploymentD Business D Official

D Study D Investment D Transit DOthers -----------(Please Specify)

26. Duration of Proposed Stay in Bangladesh:

DDiplomatic

27. Tentative Date of Arrival in Bangladesh: __ --I..I__ I<-- _D DI M M I YYYY

28. Intended Number of Entries: Single D Re Entry D Multiple D

EXTENSION OF VISA

29. Name of the FatherlMotherlSpouse/ Other (Relation) :

30. Date of Arrival: __ --'-__ ~ _in Bangladesh 0 0 I M M I YYYY

31.Visa No: 32.Type ofVisa: _

33. Date of issueo 01 M M I YYYY

34. Date of Expiry: __ .•..1 1'-- _001 M M I YYYY

35. Place ofIssue: 11====36. Purpose of Extension of Visa:

37. Duration of Proposed Extension:1__ -----'

Single D Re EntryD Multiple D38. Intended Number of Entries:

NO VISA REQUIRED FOR TRAVEL TO BANGLADESH

Nationality: 1=======

Nationality: 1================

Nationality: 1 _

43. Visa No: IL.... _

45. Date of Expiry: ------ _

47. Type of Visa: 1 1

39. Father's name:

40. Mother's name:

41. Spouse's name:

42. Date of Arrival in Bangladesh: I ID 01 M M I YYYY

44. Date ofIssue: _o 01 M M I YYYY

46. Place of issue: 1 _

o DIM MI YYYY

48. Reason For Proposed NVR: 1

49. Amount ofInvestment (For Investor): IL.... ...:' I

50. Name and Address of Company:

TRANSITION ARRIVAL VISA

51. Date of Arrival in Bangladesh: .../...f__ J-f 52. Name of check post:D 01 M M I YYYY

53. Travelled by (Vessel'sl Flight/Vehicle Name & No):1

55. Purpose of Visit to Bangladesh: I --.J

1 54. From: 1L..---:--:--r========i

56.Duration of Proposed Stay: I ----l

CHECKLIST

Recommendation from concern Ministry/ AuthoritySecurity Clearance/Security CertificateFather's/ Husband's/Mother's Visa CopyPassport copy, Last Visa & Last Arrival PageFather's/ Husband's/Mother's Passport CopyN. O. C from Sri Lankan High CommissionBi- Lateral Agreement! Multilateral AgreementTrade license of the sponsoring Company

Payment Slip D Over stay payment Slip

Marriage CertificateBirth CertificateWork PermitAffidavit

PhotoIncome Tax Certificate of the CompanyTINTIN certificate of the companyOthers _

DDDDDDDD

DDDDDDDDD

I, hereby, declare that statement given above is true and will not request to refund my paid visa fee even if myapplication is declined.

Place ---------

Date / /D D/MMI YYYY

Signature

POLICE VERIFICATION

/, /,Memo No Date:D DI M M 1 YYYY

Information's are found: IncorrectCorrect

If not correct Reasons: _

Signature and Seal of Inquiry Officer Signature and Seal of Issuing Officer

FOR OFFICIAL USE

AJuountofFee: _

Date Expiry

oMultiple Entries 0NVR

Reference No: Date: _

Visa No Date: _ \

Number of Entries 0 Extension 0Re- Entry

Recipient's Signature:Date:

Authorized SignatureDate & Seal

Visa Application Form

~Bangladesh Deputy High Commission, Karachi, Pakistan

PLEASE TYPE OR PRINT YOUR ANSWER IN THE SPACE PROVIDED BELOW EACH ITEM01. Full Name (First/Middle/ Family Name).•... -..02. Place of Birth (City / State/ Country) \ 03. Date of Birth (ddjmm/yyyy)

/ /.04. Nationality 05. Dual Nationality D Yes DNo Staple

If yes: 3 x copies of photo'" (37mm x ~7mm)Name of the Country: •

Passport Number: Identity Card Number:07. Religion 08. Sex I' 09. Marital Status .

oMale 0 Female oMarried 0 Unmarried 0Divorced 0Widowed10. Profession \11. Type of Visa

12. Passport Number (on which visa is being applied) \13. Place of Issue \14. Date of Expiry! /20

15. Spouse Name Nationality

16. Father's Name Nationality

17. Mother's Name Nationality

18. Home Address

19. Telephone 20. Fax - 21. Email22. Business/ Work Address

23. Telephone . 24. Fax 25: Email-26. Name of Employer and / or Companyi-

w

27. Telephone 28. Fax 29. Email30. Purpose of Visit (Tick appropriate box)

o Tourism (incl. Tabling/visiting relatives, etc) 0 Business/ Investment o Seminar/ Conference/ Govt. Delegation

D Cultural/ Scientific Programme o Missionary o NGOWorks oOfficial

D Expert(s)/Worker(s)/Teacher(s)/Representative(s) in Industrial/Educational/Trading Org./Sports/Artistic activities etc.

o Covr. Contractual Employment OSh.tdy / Research o Employment in UN! International Org.

o Journalism / Media (Print & Electronic) -0 Others (Specify)

31. Name and Address of Person (s), Institution or Company where you can be contacted during your stay in Bangladesh.\

32. Address while in Bangladesh 33. Telephone

34. Place and Probable Date of Arrival 35. Intended Duration of Stay .

36. Have you ever served in the Armed Forces? (if 'YES' then fill out the separate form)

37. Have you ever been to Bangladesh 38. If yes, Date and length of last visit

0 Yes o No .39. Name and Relationship of person (s) Traveling with you

40. Declaration

I declare that the above information is true and accurate

ame Date--/-/ Signature'·_0.

Please ensure that your have answered items l.'through 39 and signed the Declaration. Incomplete forms will be returned

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