X.BC.

f - 1 (hejm ff)
AhceLll HLV lPe
Rh 55 ^ 45 jxjx
ALll Rh AW cu
mNel fl paue Lla
qh
Affix the photograph
here and attest on the
photo

NZfSa
a hwmcn plLl

hqlNje J fpfV Adcl

fpf
fpfVl Ahce glj
Passport Application Form

AhceLll fal
HLV lPe Rh 30 ^
25 jxjx ALll Rh
AW cu mNel fl
paue Lla qh

AhceLll jal
HLV lPe Rh 30 ^
25 jxjx ALll Rh
AW cu mNel fl
paue Lla qh

Affix applicants
Fathers photograph
here and attest on the
photo

Affix applicants
Mothers photograph
here and attest on the
photo

Lhmj Afhu AhceLll r

Efl Rhu BhnLz

alL (*) Qqa jL ew m Ahn flZuz Serial numbers marked with star (*) marks must be filled in.
jL ew 1 haa Aee jL CwlSa (Capital Letter) flZuz Except serial number 1 all other serials must be filled in English
(Capital Letter).

* BmL fpfV Agpl ej x ________________________________ * Ahcel fLa x

Name of RPO
Application type
* AhceLa fpfVl fLa x
Type of passport applied for

pdle
Ordinary

Agpum
Official

* fpfV halZl fLa

Type of delivery

pdle
Regular

Sll
Express

eae
New

ehue
Renew

LVeaL
Diplomatic

1z

AhceLll ej (hwmu) x ________________________________________________________________

Name of Applicant (in Bengali)

2z*

AhceLll ej x _______________________________________________________________________
Name of Applicant

3z*

BhceLll ej - Afe fpfV ej kih cMa Qe pih VCf Lle z phQ 38V Arl hhql Ll khz
Name of Applicant Type as you want it to appear in your passport. Maximum 38 characters are allowed.
fbj Awn
First Part
au Awn
Second Part

(hxcx ejl nown 2u Awn mMa qh Hhw 1j Awn HLdL Awn bLm fa Awnl jTMe 1V Ol ne lM flZ Lla qh z The last
part of the name should appear in second part. Keep a blank space between two parts of the name).

4z*

fal ej x _______________________________ fn x ___________________ Saua x _____________

Fathers Name
Profession
Nationality

5z*

jal ej x ________________________________ fn x ___________________ Saua x ____________

Mothers Name
Profession
Nationality

6z

j/ /AiihLl ej x _______________________fn x ___________________ Saua x ____________

(fkS qm) Spouses/Guardians Name
Profession
Nationality
(if applicable)

7z*

See (cn J Sm) x

Place of Birth

8z*

Se alM x
Date of Birth

9z*

cnl ej ___________________________ Sml ej ______________________

Country
District

mwN (VL (
) Qq ce) x

Gender (Put (
) in appropriate box)

ce

jp

Day

Month

flo
Male
fa-1

hvpl
Year

jqm
Female

Aee
Others

10 z

Se pecf ew (kc bL) x

Birth Identification Number
(if available)

11z

Sau flQufl ew (kc bL) x

National Identification Number
(if available)

[[

12z

VACHe (kc bL) x

Tax Identification Number (if available)

13z*

EQa x
Height

14z*

hhqL Ah (VL (
) Qq ce) x

Marital Status
Put (
) in appropriate box

15z*

pxjx
cm
Ahhqa
Unmarried

hhqa
Married

C
inch
hfaL / hdh
Widower/Widow

amLff
Divorced

fn x _______________________________________________________________________________
Profession

16z*

haje WLe x
Present
Address

Nj / hp ew _____________________________ l/hL ew _________________________

Village/House No.
Road/Block No.
be ___________________________________ XLOl ___________________________
Police Station
Post Office
Sm __________________________________ fVLX _________________________
District
Post Code
qu WLe J haje WLe HLC qm VL (
)Qq ce
Put (
) if Permanent Address is same as Present Address

17z*

u WLe x
Permanent
Address

Nj / hp ew _____________________________ l/hL ew _________________________

Village/House No.
Road/Block No.
be ___________________________________ XLOl ___________________________
Police Station
Post Office
Sm __________________________________ fVLX _________________________
District
Post Code

18z

Sll kNkNl Se ge el x Agp _______________________ jhCm el _______________________

Emergency contact numbers

Office

Mobile No.

hp ________________________ CjCm WLe ______________________

Residence
email
19z*

20z

hwmcn eNlLal p x
(VL (
) Qq ce)

Sjp
by birth

hwnp
by descent

Aihpe
Migration

cnuLlZ p
Naturalization

Type of Citizenship
Put (
) in appropriate box

hhqLp
by marriage

Aee, EM Lle
Others, please specify _________________________

~a eNlL qm eNlLa fceLl cnl ej x _________________________ fpfV ew _________________

Name of the other country in case of dual citizenship
Passport No.
fa-2

21z*

fpfVl Se gp Sj pw abhm (k abm fuS qh) x

Fees Payment Information
hwL ____________________________ nM ______________________ SjLa g Hl flje ____________
Name of the Bank
Branch
Amount deposited
lnc ew __________________________________
Receipt/Transaction No.

22z

alM _______________________
Date

fh fceLa fpfVl hhlZ (fkS qm) x

Previous passport details (if applicable)

fpfV el _____________________________ Cpl e J alM ________________________________

Passport No.
Place and Date of Issue
fpfV flhael LlZ (VL (
) Qq ce) x

qle

hhqll Aefk

juc EZ

Reason for re apply

Lost

Unusable

Expired

Put (
) in appropriate box

SX el (fkS r) _________________________________________ alM ______________________
GD No. (if applicable)
Date
bel ej (k beu SX Ll quR ) ___________________________________________________________
Name of the Police Station

(wet `t eZgvb cvmcvU bevqb/weK cvmcvUi I wgK bs 22 chvR ne| Serial 22 will also be applicable for
renewal of existing passport/for issuing duplicate passport.)

AwNLl ej
ej
1z

Aj nfb Ll hmR k Ahcef fc ph ab pa Hhw Le jb ab cu bLm Aj ACeax ceu qhz

2z

Aj Al fa LlR Aj/Ajl pe h fo, k Le LlZ AihN qu fsm hcn bL AjL Abh Ajl foL

cn fahae Lll r khau MlQ flnd hd bLh Hhw hcn Ajl/Lwh Ajl pe h fol ja OVm jlcql flhqe MlQ
Ajl hd EldLl/Ajl LR bL AcukN qhz
alM x _____________________

AhceLll/AiihLl (AhceLl Af hu qm)

rl h VfpC
(Aefeu Lma)

paue

(BhceLl Sau flQuf dl e qm)

Ajl e J hnpja Efl hZa ab pa Hhw ____________________________________ (BhceLl) _________hvpl
khv Ajl flQaz ae Ajl pjM Ahcef rl / VfpC fce LlRez
paueLll AhpL WLe x ___________________________

__________________

_______________________________________________

paueLll ej J rl
alM x ______________

fpfV/Sau flQu f ew _____________________

Vmge el (kc bL) _______________________________
fa-3

(pm jql)

fmn ilgLne
ilgLne lfV Hl Se
fmn ilgLne el x _______________________________________________ alM x_____________________
AhceLll abl paa kQC x

pWL

pWL eu

pWL e qm LlZ (Saua, Ql, fh flQu, Cac) x ______________________________________________________

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

__________________________________

_________________________________

fmn ilgLne farlLl Agpll rl

fmn ilgLne lfV CpLl Agpll rl

(fmn BCX J pm)

(fmn BCX J pm)

ecne
AhceLlL ej
mMa cmmc Bhcef AhnC pwk Lla qhz
ejmMa
1z
2z
3z
4z
5z

AhceLll HLV lPe Rh (55 ^ 45 jxjx) ALll Rh AW cu mNel fl paue Lla qhz
Afhu (15 hRll Lj) AhceLll r AhceLll fa J jal HLV Ll lPe Rh (30 ^ 25 jxjx) Rh AW
cu mNel fl paue Lla qhz
Sau flQuf Abh Se pecfl gVLfz
fkS r fpL VLeLm pecpjql (kje Xl, Ceul, XCil Cac) paua gVLf cMm Lla qh z
k pLm hNZ fpfVl Ahcef J Rh paue Lla flhe x (1) pwpc pcp, (2) pV Lflnel jul, XfV jul
J LjnelNZ, (3) NSVX LjLa, (4) hnhcmu nrL, (5) EfSm floc J CEeue flocl Qulje, (6) flpil
jul, (7) hplLl LmSl nrL, (8) hplLl EQ hcmul fde nrL, (9) ceL fLl pfcL, (10) fl
LjnelNZ, (11) lu hwL J unpa pw h Lflnel eae Sau hae ml 7j J acd NXl LjLaNZ z

1z

ab pwNqLl ( AflVl ) Hl ej, BCX J rl __________________________________________________

2z

Ahce NqeLl Agpll ej, BCX J rl ____________________________________________________

3z

fpfV Cp AejceLl LjLal ej, BCX J rl _______________________________________________

4z

CpLa fpfV elx _____________________

5z

fpfV haleLl Agpll ej, BCX J rl ___________________________________________________

6z

AhceLll fpfV fl rl J alM _______________________________________________________

fa-4