Transcription of Embassy of the People's Republic of Bangladesh Washington ...
1 Embassy of the People's Republic of Bangladesh Washington , 3510 international drive , NW Washington , DC-20008, USA Phone: 202 244 0183, Fax: 202-244-2771/202-244-7830 E-mail: Website: Application Form for Travel Permit Please fill-up the form in English in BLOCK letters 1. Name (bvg) : 2. (a) Father s /Husband s Name (wcZv/ ^vgxi bvg) : (b) Mother s Name (gvZvi bvg) : 3. Date of Birth (Rb ZvwiL ) : / / Place of Birth (Rb vb) : dd mm yy 4. Permanent Address in Bangladesh (evsjv ` ki vqx wVKvbv) : Village/Road (M vg/moK) : Post Office ( cv Awdm) : Upazila/PS/Town (Dc Rjv/_vbv) : District ( Rjv) : 5.
2 Address in the United States (gvwK b hy iv eZ gvb wVKvbv) : Street (moK) : City (kni) : State (c `k) : Zip code ( Rjv) : Telephone No. (`~ivjvcbx) : E-mail (B- gBj) : 6. Present Bangladeshi Passport No. : Date of Issue : Place of issue : (eZ gvb evsjv `kx cvm cvU bs) (Bmy i ZvwiL) (Bmy i vb) 7. Reference with details, if any (cwiPq`vbKvix e w i e v , hw` _v K) : Name (bvg) : Address (wVKvbv) : Telephone No. (`~ivjvcbx) : 8. Height (cm) (D PZv): Colour of Eyes ( Pv Li is): Color of Hair (Pz ji is): 9. Visible Identification Mark(s), if any (mbv Kib wP , hw` _v K) : 10.
3 Profession /Occupation ( ckv) : 11. Reasons for applying Travel Permit : (U v fj cviwgU Av e` bi KviY) I do hereby solemnly declare that the above statements given by me is true and that I am not in possession of any other Bangladesh Passport except the one mentioned in serial No. 6. GB g g A xKvi KiwQ h, Dc i c ` Z_ vejx Avgvi vb g Z mwVK Ges wgK bs-6 G ewY Z evsjv `k cvm cvU e ZxZ Avgvi Ab Kvb evsjv `kx cvm cvU bvB| .. Signature of the Applicant Av e`bKvixi ^v i Specimen signatures of the applicant : Specimen signatures of the applicant : Affix here a 2x2 inch Photo with glue Staple extra 2-photos here
