APPLICATION FOR DUAL NATIONALITY

1 Embassy of Bangladesh 3510 Intern atio nal Dr., NW, Was hin gto n, D C , 20008, USA TEL- (20 2) 244 0 1 83 , Ext: 115/100 FA X (20 2) 244 7248 W E B - d emb assy u rg APPLICATION FOR dual NATIONALITY Please note that three (3) sets of t he entire APPLICATION form including attachments need to be submitted Please attach /staple 4 copies of 40mm X 50mm (passport size photographs) taken within the last six months (two copies with the first PLEASE FILL IN THREE COPIE S OF T HIS F RO M . P LEASE T YP E OR P RIN T I N BL OC K LETTERS . UN LE SS O TH ER WI SE ME NTIONED, PLE ASE C OMPLE TE AL L ITEM S OR WRIT E "N/A" (N OT APP LIC ABLE) )IF NEEDED. set and one copy each with the second and third set. PLE ASE DO N O T U S E GLUE. 1. Name 2. Date of birth [e. g. 26-Mar-1971] 3. Pla ce ofbirth (district, in case of Bangladesh) 4. Present address (in the United States) 5. Permanent address (inBangladesh) Street House/Apt # City State Home telephone Zip code Cell: Name of father 9.

2 Permanent address of father (inBangladesh) Place of birth of father: Name of mother Place ofbirth of mother: Name of s pouse: Place of birth of spouse: 10. Name and address ofchildren (Please use separate sheet, if needed) a. b. c. 11. Name and address relatives (living i n Bangladesh) who can be contacted for referen ce (at least one): a. Relationsihip b. Relationsihip c. Relationsihip Page - 2 12. Particulars ofproperties i n Bangladesh with addresss [Please attach separate sheet, if needed] 13. Date of first leaving Bangladesh Bangladesh Passport # Pla ce ofissue [e. g. 26-Mar-1971] [Please attach photocopy of Bangladesh Passport] [Please attach photocopy of U S Passport] Date ofissue 15. Date ofacquisition of foreign citizenship Foreign Passport # [e. g. 26-Mar-1971] [Please attach photocopy of U S na turalization certif icate] Place of issue Date ofissue Date ofexpiry [e.]

3 G. 26-Mar-1971] [e. g. 26-Mar-1971] 17. Present occup ation 21. Work address 18. Annual income (in US $) 19. Source ofincome [Please attach separate sheet if needed] City State Zip code 20. Academic or specia l qualification [Please attach Telephone separate sheet if needed] 22. Details of remittancemade to Bangladesh [Please attach copies of receipts] Name ofthe Bank with address Account # 23. Knowledgeof Bangla Read Write Speak 24. Reasons for seeking citizenship of Bangladesh 25. a. Money order # Issued by Amount in US $ Declaration: I do hereby solemnly affirm and swear that the information provided in this APPLICATION fordual NATIONALITY are true, correct an d complete. Date Signature ofthe ap p l ic a nt [e. g. 26-Mar-1971] FOR OFFICIAL USE ONLY. Receipt # Date Amount ( US$) Observation ofthe Mission [e. g. 26-Mar-1971] Received by Signature ofthe issuing authority Date [e. g.

4 26-Mar-1971] DECLARATION OF ASSETS (Page 3 of the APPLICATION set) 1. Name 2. Father's Name Description ofmoveable assets Description Quantity/ Number Value in U S $ Description ofimmoveable assets Description Nature of asset Quantity (area etc.) Value in U S $ I do hereby solemnly affirm a nd swear that the information provided above are true, correct and complete.. Date e. g. 26-Mar-1971 Signature ofthe applicant STATEMENT OF ACTIVITIES IN THE LAST 5 YEARS (Page 4 of the APPLICATION set) 1. Name 2. Father's Name 3. Description of activities Description of Activities (Education/service/business) From To I do hereby solemnly affirm a nd swear that the information provided above are true, correct and complete. Date e. g. 26-Mar-1971 Signature ofthe applicant AFFIDAVIT FOR dual NATIONALITY CERTIFICATE (Page 5 of the APPLICATION set) I, ( name) Son of Daughter of Spouse of Present address (in the United States) Permanent address (in Bangladesh) Street House/Apt # Ci ty State Zip code Present occup ation: do hereby solemnly affirm a nd swear that the information provided in m y APPLICATION for dual NATIONALITY a re true, correct and complete.

5 In witness whereof, I have signed this affidavit before the Minister Counselor/ Notary Public on t he day of First Secretary Signature of t he deponent (Applicant) The deponent has signed in my presence. Signature of Embassy Official or Notary Public Instruction and Requirements for dual NATIONALITY APPLICATION Please duly fill-in the prescribed APPLICATION form (three sets) and fulfill all requirements, who is seeking dual NATIONALITY Certificate. The following may be noted before submission of the APPLICATION form: a) If the applicant is person temporarily residing in Bangladesh, the APPLICATION shall be submitted directly to the Secretary, Ministry of Home Affairs of the Government of Bangladesh; b) If the applicant lives in a foreign country, the APPLICATION should be sent through the Bangladesh Diplomatic Mission / Consulate to that country; and c) Where there is no Bangladesh Mission or Consulate in a country of applicant s residence, the APPLICATION may be sent through Bangladesh Mission or Consulate in the country nearest to that country.

6 Each APPLICATION set shall be accompanied by: 1. Affidavit affirming the truth of the statement made in the APPLICATION and signed before the Minister / Counselor / First Secretary / Notary Public or persons of equivalent status of the Embassy of Bangladesh in Washington DC (please see page 5); 2. Documentary evidence regarding remittances to Bangladesh for last 3-years, if any; 3. Copy of foreign Passport and Citizenship Certificate or Naturalization Certificate; 4. Declaration of Assets (Movable / Immovable) in Bangladesh, if any (please see page 3). Please use a separate sheet if required. Statement of Parent's assets should be given if the applicant does not have any asset in his /her name; 5. Statement of activities for past 5-years (service, education, business etc.) since first departure from Bangladesh (Please see page 4). Please use separate sheet if required; 6. Recent colored passport size 4-photographs (print applicant s name on the back); 7.

7 Copy of Birth Certificate of children born in the USA (if she/he is the applicant). 8. Copy of Parent's Bangladesh Passport (page 1-7, if passport is old and hand-written) or dual Citizenship Certificate in the case of child applicant born in the USA; 9. Photocopy of Bangladesh Passport (page 1-7, if passport is old and hand-written) FEE: Please tender the US $77 (Seventy-Seven US Dollars) in the form of Money order/Bank Draft/Certified Check/Cashier Check payable to the 'Embassy of Bangladesh'. Personal checks or Cash are not accepted.