f¡a¡-1

NZfÊS¡a¿»£ h¡wm¡−cn plL¡l h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl

−j¢ne ¢l−Xhm f¡p−f¡VÑ A¡−hce glj Machine Readable Passport Application Form

• A¡−hce fœ¢V fl̈Z Ll¡l f¨−hÑ Ae¤NÊqf§hÑL −no fªù¡u h¢ZÑa p¡d¡le ¢e−cÑne¡pj§q paLÑa¡l p¢qa f¡W Ll²ez

Please read carefully the General Instructions at the last page before filling the form. • a¡lL¡ (*) ¢Q¢q²a œ²¢jL ew …−m¡ AhnÉ f¨lZ£uz

Serial numbers marked with star (*) marks must be filled in.

• œ²¢jL ew 1 hÉa£a AeÉ¡eÉ œ²¢jL Cw−lS£−a (Capital Letters) f¨lZ£u z Except serial number 1, all other serials must be filled in English (Capital Letters).

* B’¢mL f¡p−f¡VÑ A¢gp/h¡wm¡−cn ¢jne x * A¡−hc−el fÊL«¢a x ea¤e f§ex fËc¡e Name of RPO / Bangladesh Mission Application type New Reissue

* A¡−hceL«a f¡p−f¡−VÑl fÊL«¢a x p¡d¡le A¢g¢pu¡m L¤V¯e¢aL Type of passport applied for Ordinary Official Diplomatic

* f¡p−f¡VÑ ¢hal−Zl fÊL«¢a x p¡d¡le Sl¦l£ Type of delivery Regular Express 1z A¡−hceL¡l£l e¡j (h¡wm¡u) x ________________________________________________________________ Name of Applicant (in Bengali)

2z* A¡−hceL¡l£l e¡j x _______________________________________________________________________ Name of Applicant

3z* B−hceL¡l£l e¡j - A¡f¢e f¡p−f¡−VÑ e¡j −ki¡−h ®cM−a Q¡e ®pi¡−h V¡Cf Ll¦e z p−hÑ¡μQ 48¢V Arl hÉhq¡l Ll¡ k¡−hz Name of Applicant – Type as you want it to appear in your passport. Maximum 48 characters are allowed.

(e¡−jl ®no¡wn 2u Aw−n ¢mM−a q−h Hhw 1j Aw−n HL¡¢dL Awn b¡L−m fË¢a Aw−nl j¡TM¡−e 1¢V Ol n§eÉ ®l−M f§lZ Ll−a q−h z The last

part of the name should appear in second part. Keep a blank space between two parts of the name).

fÊbj Awn First Part (Given Name)

¢àa£u Awn Second Part (Surname)

4z* ¢fa¡l e¡j x _______________________________ −fn¡ x ___________________ S¡a£ua¡ x _____________ Father’s Name Profession Nationality

5z* j¡a¡l e¡j x ________________________________ −fn¡ x ___________________S¡a£ua¡ x ____________ Mother’s Name Profession Nationality

6z ð¡j£/ Ù»£-l e¡j x ________________ _______−fn¡ x ___________________ S¡a£ua¡ x ____________ (fÊ−k¡SÉ q−m) Spouse’s Name Profession Nationality

(if applicable)

7z A¢ii¡h−Ll e¡j x _____________ __________−fn¡ x ___________________ S¡a£ua¡ x ____________ (fÊ−k¡SÉ q−m) Guardian’s Name Profession Nationality

(if applicable)

A¡−hceL¡l£l HL¢V l¢Pe 55 ^ 45 ¢jx¢jx A¡L¡−ll R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl

paÉ¡ue Ll−a q−h

Affix the photograph

here and attest on the photo

¢X.BC.¢f glj - 1 (¢he¡j¨−mÉ fÊ¡fÉ)

A¡−hceL¡l£l ¢fa¡l HL¢V l¢Pe 30 ^ 25 ¢jx¢jx A¡L¡−ll R¢h

A¡W¡ ¢c−u m¡N¡−e¡l fl paÉ¡ue Ll−a q−h Affix applicant’s

Father’s photograph here and attest on the

photo

A¡−hceL¡l£l j¡a¡l HL¢V l¢Pe 30 ^ 25 ¢jx¢jx A¡L¡−ll R¢h A¡W¡ ¢c−u m¡N¡−e¡l

fl paÉ¡ue Ll−a q−h Affix applicant’s

Mother’s photograph here and attest on the

photo

−Lhmj¡œ 15 hvp−ll e£−Q AfË¡çhuú A¡−hceL¡l£l −r−œ Ef−l¡š² R¢hàu fË−u¡Se z

hÉ¢š²Na J e¡N¢lLaÄ pwœ²¡ñ abÉ (Personal & Citizenship Details)

Bangladesh Embassy, Washington D.C.

f¡a¡-2

8z* ¯hh¡¢qL AhÙÛ¡ ( ) ¢Qq² ¢ce x A¢hh¡¢qa ¢hh¡¢qa ¢hfaÀ£L / ¢hdh¡ a¡m¡LfÊ¡f¹ Marital Status Unmarried Married Widower/Widow Divorced Put ( ) in appropriate box 9z* −fn¡ x _____________________________________________________________________________ _ Profession

A¢g¢pu¡m f¡p−f¡−VÑl −r−œ x (In case of Official Passport)

A¢g−pl e¡j x ____________________________________________ Ahpl NÊq−el a¡¢lM x ________________

10z* SeÈÙÛ¡e (®cn J −Sm¡) x ®c−nl e¡j ___________________________ −Sm¡l e¡j ______________________ Place of Birth Country District

11z* SeÈ a¡¢lM x ¢ce j¡p hvpl Date of Birth Day Month Year

12z* ¢mwN ( ) ¢Qq² ¢ce x f¥l¦o j¢qm¡ AeÉ¡eÉ Gender ( ) in appropriate box Male Female Others

13z* SeÈ pecfœ ew x

Birth Identification Number

Or Abh¡ S¡a£u f¢lQuf−œl ew x

National Identification Number

14z ¢VA¡CHe (k¢c b¡−L) x

Tax Identification Number (if available)

15z* EμQa¡ x −px¢jx Or C¢’ 16z* djÑ x Height cm Abh¡ inch Religion

17z* h¡wm¡−cn£ e¡N¢lL−aÆl p§œ x S¸jp§−œ hwnp§−œ A¢ih¡pe ®cn£uLlZ p¤−œ (¢VL ( ) ¢Qq² ¢ce) by birth by descent Migration Naturalization

Type of Citizenship ¯hh¡¢qLp§−œ AeÉ¡eÉ, E−õM Ll¦e

Put ( ) in appropriate box by marriage Others, please specify __________________ _______

18z ®~àa e¡N¢lL q−m e¡N¢lLaÆ fÊc¡eL¡l£ ®c−nl e¡j x _________________________ f¡p−f¡VÑ ew _________________ Name of the other country in case of dual citizenship Passport No.

19z* haÑj¡e ¢WL¡e¡ x (h¡wm¡−c−n A¡−hc−el ®r−œ fË−k¡SÉ) (Applicable only when applying in Bangladesh) Present

Address NÊ¡j / h¡p¡ _____________________ ________ l¡Ù¹¡/hÓL/−pƒl _______________ ______ Village/House Road/Block /Sector

b¡e¡ ___________________________________ X¡LOl ___________________________ Police Station Post Office

−Sm¡ __________________________________ −f¡ØV®L¡X District Post Code ®g¡e eðl C-®jCm ¢WL¡e¡ Contact Number e-mail Address

Øq¡u£ ¢WL¡e¡ J haÑj¡e ¢WL¡e¡ HLC q−m ¢VL ( )¢Qq² ¢ce Put ( ) if Permanent Address is same as Present Address

20z* ÙÛ¡u£ ¢WL¡e¡ x NÊ¡j/h¡p¡ _______________________ ______ l¡Ù¹¡/hÓL/−pƒl________________________ Permanent Village/House Road/Block /Sector

Address b¡e¡ ___________________________________ X¡LOl ___________________________ Police Station Post Office

−Sm¡ __________________________________ −f¡ØV−L¡X _________________________ District Post Code

®g¡e eðl C-®jCm ¢WL¡e¡ Contact Number e-mail Address

- -

Name of the Office Date of Retirement

f¡a¡-3

21z ¯h−c¢nL ¢WL¡e¡ x (¯h−c¢nL ¢WL¡e¡ −Lhmj¡œ h¡wm¡−cn ¢jn−e A¡−hc−el ®r−œ fË−k¡SÉ) (Applicable only when applying in Bangladesh Missions)

¢WL¡e¡

®cn ®g¡e/gÉ¡„ eðl C-®jCm ¢WL¡e¡

22z* Sl¦l£ fË−u¡S−e ®k¡N¡−k¡−Nl SeÉ hÉ¢š²l ¢hhlZ x (Emergency contact person’s details)

e¡j x A¡−hceL¡l£l p¡−b pÇfLÑ x Name Relationship with the applicant

¢WL¡e¡ x Address

®g¡e/gÉ¡„ eðl C-®jCm ¢WL¡e¡

Phone/Fax Number e-mail Address

23z f§−hÑ fÊc¡eLªa f¡p−f¡VÑ eðl (fÊ−k¡SÉ q−m) x Cp¤Él ÙÛ¡e J a¡¢lM Previous passport details (if applicable) Place and Date of Issue

f¡p−f¡VÑ f¢lhaÑ−el L¡lZ ( ) ¢Qq² ¢ce x f¢lhaÑe hÉhq¡−ll Ae¤fk¤š² −ju¡c Eš£ZÑ q¡l¡−e¡ Reason for re apply Conversion Unusable Expired Lost

Put ( ) in appropriate box

¢S¢X eðl (fÊ−k¡SÉ ®r−œ) b¡e¡l e¡j a¡¢lM GD No. (if applicable) Name of the Police Station Date

24z A¡−hce f−œl p¡−b pwk¤š² c¢mm¡¢c x (Enclosures attached with the application form)

S¡a£u f¢lQuf−œl g−V¡L¢f SeÈ ¢ehåe pe−cl g−V¡L¢f plL¡l£ A¡−c−nl (¢SJ) g−V¡L¢f (Copy of National ID) (Copy of Birth RegistrationCertificate) (fË−k¡SÉ ®r−œ) (Copy of Government Order)

R¡sf−œl (HeJ¢p) L¢f ¢hcÉj¡e f¡p−f¡−VÑl g−V¡L¢f ®VL¢eLÉ¡m pe−cl g−V¡L¢f (fË−k¡SÉ ®r−œ)(Copy of NOC) (fË−k¡SÉ ®r−œ)(Copy of Previous Passport) (fË−k¡SÉ ®r−œ)(Copy of Technical Certificates) ¢VA¡CHe pe−cl g−V¡L¢f ¢f¢XHp/Ahp®ll a¡¢l®Ml fÊj¡efœ (fË−k¡SÉ ®r−œ) (fË−k¡SÉ ®r−œ) (PDS/Proof of Retirement Date) (Copy of TIN Certificate)

25z* f¡p−f¡−VÑl SeÉ ¢gp Sj¡ pwœ¦¡¿¹ abÉ¡hm£ (−k abÉ…−m¡ fË−k¡SÉ q−h) x Payment Information

hÉ¡wL/h¡wm¡−cn ¢jne Sj¡Lªa ¢g Hl f¢lj¡e (V¡L¡/j¡¢LÑe Xm¡l )

Name of the Bank/Bangladesh Mission Amount deposited (US$ in case of Bangladesh Missions)

n¡M¡ l¢nc ew a¡¢lM Branch Receipt/Transaction No. Date

1z A¡¢j nfb L−l hm¢R ®k A¡−hcef−œ fÊcš ph abÉ paÉ Hhw ®L¡e ¢jbÉ¡ abÉ ¢c−u b¡L−m A¡¢j A¡Ceax cäe£u qhz

2z A¡¢j A¡−l¡ fÊ¢a‘¡ Ll¢R A¡¢j/A¡j¡l p¿¹¡e h¡ ®f¡oÉ, ®k ®L¡e L¡l−Z Ai¡hNÊÙÛ q−u fs−m ¢h−cn ®b−L A¡j¡−L Abh¡ A¡j¡l ®f¡oÉ−L ®c−n fÊaÉ¡haÑe

Ll¡l ®r−œ k¡ha£u MlQ f¢l−n¡−d h¡dÉ b¡Lh Hhw ¢h−c−n A¡j¡l/A¡j¡l p¿¹¡e h¡ ®f¡−oÉl jªaɤ OV−m jl−c−ql f¢lhqe MlQ A¡j¡l °hd Ešl¡¢dL¡l£/A¡j¡l L¡R

®b−L A¡c¡u−k¡NÉ q−hz

a¡¢lM x _____________________ A¡−hceL¡l£l/A¢ii¡h®Ll (A¡−hceL¡l£ AfÊ¡ç huú q−m) ü¡rl h¡ ¢VfpC (Aef−eu L¡¢m−a)

Overseas Address

Address

Country Phone/Fax Number e-mail Address

AwN£L¡l e¡j¡ (Declaration)

(in Bangladesh)

Vill/House Road/Block/Sector

PS PO: District:

f¡a¡-4

A¡j¡l ‘¡e J ¢hnÄ¡pj−a Ef−l h¢ZÑa abÉ paÉ Hhw B−hceL¡l£ hvpl k¡hv A¡j¡l f¢l¢Qaz ¢a¢e A¡j¡l pjȤ−M A¡−hcef−œ ü¡rl /

¢VfpC fËc¡e L−l−Rez

paÉ¡ueL¡l£l A¡h¡¢pL ¢WL¡e¡ x

paÉ¡ueL¡l£l e¡j J ü¡rl

f¡p−f¡VÑ/S¡a£u f¢lQu fœ ew a¡¢lM x _____________

−V¢m−g¡e eðl (k¢c b¡−L) (p£m ®j¡ql)

f¤¢mn ®i¢l¢g−Lne eðl x _______________________________________________ a¡¢lM x_____________________

A¡−hceL¡l£l a−bÉl paÉa¡ k¡Q¡C x

p¢WL e¡ q−m L¡lZ (h¡wm¡−cn£ e¡N¢lL ee/p¡S¡fË¡ç/ j¡jm¡d£e/ ¢WL¡e¡ p¢WL eu/ AeÉ¡eÉ L¡lZ) x

_____________________________ ________________________ _____________________________

fË¢a−hce CpɤL¡l£ A¢gp¡−ll ü¡rl p¤f¡li¡C¢Sw A¢gp¡−ll ü¡rl fË¢a−hce fÊ¢aü¡rlL¡l£ A¢gp¡−ll ü¡rl

(f¤¢mn BC¢X J p£m) (f¤¢mn BC¢X J p£m) (f¤¢mn BC¢X J p£m)

A¡−hceL¡l£−L ¢ejÀ¢m¢Ma c¢mm¡¢c B−hcef−œ AhnÉC pwk¤š² Ll−a q−h 1z plL¡l£, A¡d¡plL¡l£, ü¡ušn¡¢oa J l¡øË¡uaÄ pwÙÛ¡l ÙÛ¡u£ LjÑLaÑ¡/LjÑL¡l£, AhplfË¡ç plL¡l£ Q¡L¤l£S£¢h J a¡−cl ¢eiÑln£m Ù»£/ü¡j£ Hhw plL¡l£ Q¡L¤l£S£¢hl 15 (f−el) hvp−ll Lj hu−pl p¿¹¡e, 5 (fy¡Q)/10 (cn) hvp−ll A¢aœ¦¡¿¹, pjfÑeLªa (p¡−lä¡lX) ®cl SeÉ HL¢V glj J AeÉ¡eÉ−cl ®r−œ ea¤e f¡p−f¡−VÑl SeÉ 02 (c¤C) L¢f f§lZLªa f¡p−f¡VÑ glj c¡¢Mm Ll−a q−h z 2z AfË¡çhuú (15 hR−ll Lj) A¡−hceL¡l£l −r−®œ A¡−hceL¡l£l ¢fa¡ J j¡a¡l HL¢V L−l l¢Pe R¢h (30 ^ 25 ¢jx¢jx) R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl paÉ¡ue Ll−a q−hz 3z S¡a£u f¢lQufœ Abh¡ SeÈ ¢ehåe pec Hhw fË−k¡SÉ ®r−œ fË¡p¢‰L ®VL¢eLÉ¡m pecpj§−ql (−kje X¡š²¡l, C¢”¢eu¡l, XË¡Ci¡l CaÉ¡¢c) paÉ¡¢ua g−V¡L¢fz 4z −k pLm hÉ¢š²NZ f¡p−f¡−VÑl A¡−hcefœ J R¢h fËaÉ¡ue J paÉ¡ue Ll−a f¡l−he- pwpc pcpÉ, ¢p¢V L−fÑ¡−ln−el ®jul, ®Xf¤¢V ®jul J L¡E¢¾pmlNZ, ®N−S−VX LjÑLaÑ¡, f¡h¢mL ¢hnÄ¢hcÉ¡m−ul ¢nrL, Ef−Sm¡ f¢lo−cl ®Qu¡ljÉ¡e J i¡Cp ®Qu¡ljÉ¡e, CE¢eue f¢lo−cl ®Qu¡ljÉ¡e, ®f±lpi¡l ®jul J ®f±l L¡E¢¾pmlNZ, ®hplL¡l£ ¢hnÄ¢hcÉ¡m−ul AdÉ¡fL, −hplL¡l£ L−m−Sl AdÉr, −hplL¡l£ EμQ ¢hcÉ¡m−ul fËd¡e ¢nrL, S¡a£u °c¢eL f¢œL¡l pÇf¡cL, ®e¡V¡l£ f¡h¢mL J A¡d¡plL¡l£/ü¡ušn¡¢pa/l¡øËu¡š pwÙÛ¡l S¡a£u ®hae ®ú−ml 7j J ac¤dÄÑ ®NË−Xl LjÑLaÑ¡NZ z 5z fË−k¡SÉ ®r−œ fË¡p¢‰L ¢S J (GO)/ He J ¢p (NOC) c¡¢Mm Ll−a q−h z 6z L§V¯e¢aL f¡p−f¡VÑ m¡−il ®k¡NÉ A¡−hceL¡l£NZ−L f§lZLªa glj J pwk¤¢š²pj¤q fll¡øË j¿»Z¡m−u Sj¡ ¢c−a q−h z 7z e¡−jl pw¢rçl©−fl f¢lh−aÑ f§ZÑl©−f ( ®kje-−j¡x/MD. Hl ÙÛ−m ®j¡q¡jÈc/MOHAMMAD) ¢mM¡ h¡“e£u z ¢nr¡Na h¡ Q¡L¤l£p¤−œ fË¡ç fch£pj§q (−kje X¡š¦¡l, C¢”¢eu¡l, Xƒl, ¢fHCQ¢X CaÉ¡¢c) e¡−jl Awn ¢q−ph f¢lN¢Za q−h e¡ z gl−jl œ¦¢jL ew 3 f§l−Zl ®r−œ, HL¡¢dL Awn b¡L−m fË¢a Aw−nl j¡TM¡−e 1¢V Ol n§eÉ ®l−M f§lZ Ll−a q−h z A¡−hceL¡l£l ¢fa¡, j¡a¡, ü¡j£/Ù»£ jªa q−mJ, a¡l/a¡−cl e¡−jl f§−hÑ "jªa/jlýj/Late' ®mM¡ k¡−h e¡ z

1z abÉ pwNËqL¡l£ (Af¡−lVl) Hl e¡j, BC¢X J ü¡rl

2z A¡−hce NÊqeL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl

3z f¡p−f¡VÑ Cpɤ Ae¤−j¡ceL¡l£ LjÑLaÑ¡l e¡j, BC¢X J ü¡rl

4z Cp¤ÉL«a f¡p−f¡VÑ eðlx f¡p−f¡VÑ ¢haleL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl

5z A¡−hceL¡l£l f¡p−f¡VÑ fÊ¡¢çl ü¡rl J a¡¢lM

p¢WL p¢WL eu

fËaÉue (Certification)

f¤¢mn ®i¢l¢g−Lne ¢l−f¡VÑ(Police Verification Report)

¢e−cÑne¡ (General Instruction)

A¢g−pl hÉhq¡−ll SeÉ (FOR OFFICIAL USE ONLY)

No need to fill-up this page by the Applicant in abroad

IImmppoorrttaanntt iinnffoorrmmaattiioonn oonn RRee--iissssuuee // RReenneeww ooff aann eexxiissttiinngg

MMRRPP ((MMaacchhiinnee RReeaaddaabbllee PPaassssppoorrtt)) 1. If you do not wish to change your photograph / signature: you may not need to visit the

Embassy physically. Please fill in an MRP application form (in PDF format, without barcode) and send it to the Embassy by postal mail along with the following (requirements):

(a) One copy of recent photograph (size 55x45mm); (b) Photocopy of the current passport with original; (c) Photo copy of 17-digit Birth Certificate or National ID Card (which mentioned in your

previous MRP); (d) A money order/bank draft of US$ 110 (for Ordinary Delivery) / US$ 220 (for Express

Delivery) addressed to the ‘Embassy of Bangladesh’; (e) Proof of Occupation (if applicant is Engineer, Physician, Researcher, Teacher, Student,

Driver or any special occupation). For Private Service, no proof of occupation is required;

(f) Copy of Marriage Certificate (if applicant is married); (g) Proof of non-US citizen or any foreign national (Photocopy of Green Card/Permanent

Resident Card or Work Permit or I-20 etc). If applicant is US citizen or any foreign national, please provide a photocopy of Dual National Certificate.

2. If you want to change your photograph/signature in your re-issued passport, please contact

the Embassy over phone to set an appointment; and follow the procedure as you would do during obtaining a new MRP. You may also visit one of our mobile MRP enrolment camp when it comes to your area. Please see the above-mentioned schedule, if any. For more information, please call us or keep an eye on our website.

3. If a machine readable passport was issued when the holder was a minor due to which

biometric information was not recorded, and now the holder has attained 15 years of age, the holder needs to visit the Embassy or a mobile enrolment facility. In this case, please follow the procedure of obtaining of a new MRP as mentioned in 2. above.

Mailing service: A self-addressed prepaid envelope for return mail service preferably USPS Certified with tracking number /Express Mail Flat Rate (from US Post Office) / UPS or FedEx Prepaid label by the applicant. Your passport will be sent to you once it is received from Dhaka. The return envelope is not required if the applicant wishes to collect the MRP (Passport) from the Embassy physically. Processing time for MRP: Application and requirements are received at the counter between 10:00 a.m.–1:00 p.m., Monday to Friday, except holidays. Delivery time is from 3:30–5:00 p.m. Please note that the Bangladesh Embassy needs at least 45 to 60 days (60-days for Ordinary Delivery / 45-days for Express Delivery) to process the MRP application.

i. Please check the spelling and accuracy of the data that you have provided while filling in your application form since these will be reflected in your passport and fulfill all requirements to avoid any delay in processing;

ii. Any misrepresentation of facts may lead to cancellation of MRP at any time.