MYcÖRvZš¿x evsjv‡`k miKvi MYcÖRvZš¿x evsjv‡`k miKvi

(Govt. of the People’s Republic of Bangladesh) (Govt. of the People’s Republic of Bangladesh)
(ewnM©gb KvW©/Departure Card) (ewnM©gb KvW©/Departure Card)

1. bvg 1. bvg
Name Name
Day Month Year Day Month Year
2. †m· cyiæl gwnjv 3. Rb¥ ZvwiL 2. †m· cyiæl gwnjv 3. Rb¥ ZvwiL
Sex Male Femala Date of Birth Sex Male Femala Date of Birth

4. RvZxqZv 4. RvZxqZv
Nationality Nationality Day Month Year
Day Month Year
5. cvm‡cvU© b¤^i 6.†gqv` DËx‡Y©i ZvwiL 5. cvm‡cvU© b¤^i 6.†gqv` DËx‡Y©i ZvwiL
Passport Number Date of Expiry Passport Number Date of Expiry
Day Month Year Day Month Year
7. d¬vBU b¤^i 8. cÖ¯’v‡bi ZvwiL 7. d¬vBU b¤^i 8. cÖ¯’v‡bi ZvwiL
Flight Number Date of Departure Flight Number Date of Departure

9. evsjv‡`‡k Ae¯’vbKvjxb wVKvbv 9. evsjv‡`‡k Ae¯’vbKvjxb wVKvbv

(we‡`kx bvMwi‡Ki Rb¨) (we‡`kx bvMwi‡Ki Rb¨)
Address in Bangladesh Address in Bangladesh
(For Foreigners) (For Foreigners)

10. evsjv‡`‡ki bvMwi‡Ki Rb¨ For Bangladesh Nationals 10. evsjv‡`‡ki bvMwi‡Ki Rb¨ For Bangladesh Nationals

a. wfmv b¤^i Day Month Year a. wfmv b¤^i b. †gqv` DËx‡Y©i ZvwiL Day Month Year
b. †gqv` DËx‡Y©i ZvwiL
Visa Number Date of Expiry Visa Number Date of Expiry

c. wfmvi cÖKvi d. åg‡Yi D‡Ïk¨ c. wfmvi cÖKvi d. åg‡Yi D‡Ïk¨

Type of Visa Purpose of Visit Type of Visa Purpose of Visit

mxj mxj
Seal Seal

hvÎxi ¯^vÿi hvÎxi ¯^vÿi

Passanger’s Signature Passanger’s Signature

Day Month Year Day Month Year

ZvwiL: ZvwiL:
Date Date

MYcÖRvZš¿x evsjv‡`k miKvi MYcÖRvZš¿x evsjv‡`k miKvi

(Govt. of the People’s Republic of Bangladesh) (Govt. of the People’s Republic of Bangladesh)
(ewnM©gb KvW©/Departure Card) (ewnM©gb KvW©/Departure Card)

1. bvg 1. bvg
Name Name
Day Month Year Day Month Year
2. †m· cyiæl gwnjv 3. Rb¥ ZvwiL 2. †m· cyiæl gwnjv 3. Rb¥ ZvwiL
Sex Male Femala Date of Birth Sex Male Femala Date of Birth

4. RvZxqZv 4. RvZxqZv
Nationality Nationality Day Month Year
Day Month Year
5. cvm‡cvU© b¤^i 6.†gqv` DËx‡Y©i ZvwiL 5. cvm‡cvU© b¤^i 6.†gqv` DËx‡Y©i ZvwiL
Passport Number Date of Expiry Passport Number Date of Expiry
Day Month Year Day Month Year
7. d¬vBU b¤^i 8. cÖ¯’v‡bi ZvwiL 7. d¬vBU b¤^i 8. cÖ¯’v‡bi ZvwiL
Flight Number Date of Departure Flight Number Date of Departure

9. evsjv‡`‡k Ae¯’vbKvjxb wVKvbv 9. evsjv‡`‡k Ae¯’vbKvjxb wVKvbv

(we‡`kx bvMwi‡Ki Rb¨) (we‡`kx bvMwi‡Ki Rb¨)
Address in Bangladesh Address in Bangladesh
(For Foreigners) (For Foreigners)

10. evsjv‡`‡ki bvMwi‡Ki Rb¨ For Bangladesh Nationals 10. evsjv‡`‡ki bvMwi‡Ki Rb¨ For Bangladesh Nationals

a. wfmv b¤^i Day Month Year a. wfmv b¤^i b. †gqv` DËx‡Y©i ZvwiL Day Month Year
b. †gqv` DËx‡Y©i ZvwiL
Visa Number Date of Expiry Visa Number Date of Expiry

c. wfmvi cÖKvi d. åg‡Yi D‡Ïk¨ c. wfmvi cÖKvi d. åg‡Yi D‡Ïk¨

Type of Visa Purpose of Visit Type of Visa Purpose of Visit

mxj mxj
Seal Seal

hvÎxi ¯^vÿi hvÎxi ¯^vÿi

Passanger’s Signature Passanger’s Signature

Day Month Year Day Month Year

ZvwiL: ZvwiL:
Date Date