Bangladesh Visa Application Form

PLEASE TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW EACH ITEM 01. 02. FULL NAME (First/Middle/Family Name) PLACE OF BIRTH (City/State/Country) 03. 03. 04. NATIONALITY 05. SEX Male 07. 09. PROFESSION PASSPORT NUMBER Female 08. 10. 06. DATE OF BIRTH (dd/mm/yyyy) ________ / ________ / ________ Staple 3 x copies photo (37 mm x 37 mm)

MARITAL STATUS Married Unmarried Divorced Widowed

TYPE OF VISA PLACE OF ISSUE 11. DATE OF EXPIRY

11. ________ / ________ / 20 ______ 12. 13. 14. 15. 16. 19. 20. 23. 24. 27. 88. 88. 88. SPOUSES NAME FATHERS NAME MOTHERS NAME HOME ADDRESS TELEPHONE : BUSINESS / WORK ADDRESS TELEPHONE : NAME OF EMPLOYER TELEPHONE : PURPOSE OF VISIT (Tick appropriate box) Tourism (Incl. tablig / visiting relatives, etc.) Cultural / Scientific Programme Business / Investment Missionary Seminar / Conference / Govt. Delegation NGO Works Official 25. FAX : 26. EMAIL 21. FAX : 22. EMAIL: 17. FAX : 18. EMAIL: NATIONALITY NATIONALITY NATIONALITY

Expert(s) / Worker(s) / Teacher(s) / Representative(s) in Industrial / Educational / Trading Org. / Sports / Artistic Activities, etc. Study / Research Employment in UN / International

88. Government Contractual Employment Organizations 88. 28. Journalist / Media (Print & Electronic

Others (Specify)

NAME AND ADDRESS OF PERSON(S), INSTITUTION OR COMPANY WHERE YOU CAN BE CONTACTED

29.

ADDRESS WHILE IN BANGLADESH

30.

TELEPHONE

31.

PLACE AND PROBABLE DATE OF ARRIVAL

32.

INTENDED DURATION OF STAY

33. 88.

HAVE YOU EVER BEEN TO BANGLADESH Yes No

34.

IF YES, DATE AND LENGTH OF LAST VISIT

35.

NAME AND RELATIONSHIP OF PERSON(S) TRAVELLING WITH YOU

36. 88.

DECLARATION I declare that the above information is true and accurate

88. NAME __________________________________________ DATE ________ / _______ / ________ SIGNATURE ________________________ 88. ( dd / mm / yyyy ) Please ensure that you have answered items 1 through 35 and signed the declaration. Incomplete forms will be returned.

R OFFICIAL USE ONLY (Do not write in this space) FOR OFFICIAL USE ONLY (Do not write in this space)

Date _____ / _____ / ______ Visa No. _________________________________ Classification ______________________ Type : Single / Multiple / Transit Date of Issue _____________________________ Validity __________________________ Authorized Duration _______________________ Refused on _______________________________ Reviewed by ______________________ Comments :

(Name and Designation of the Issuing Authority with seal)

B.G.P. 2002/03-4759 Com/A(16) 2,00,000 copies, 2003