¢X.BC.

¢f - 1 (¢he¡j¨−mÉ fÊ¡fÉ)

A¡−hceL¡l£l HL¢V l¢Pe

R¢h 55 ^ 45 ¢jx¢jx A¡−hceL¡l£l ¢fa¡l A¡−hceL¡l£l j¡a¡l
A¡L¡−ll R¢h A¡W¡ ¢c−u NZfÊS¡a¿»
¡a¿»£ h¡wm¡−cn plL¡l HL¢V l¢Pe R¢h 30 ^
25 ¢jx¢jx A¡L¡−ll R¢h
HL¢V l¢Pe R¢h 30 ^
25 ¢jx¢jx A¡L¡−ll R¢h
m¡N¡−e¡l fl paÉ¡ue Ll−a h¢ql¡Nje J f¡p−f¡VÑ A¢dcçl A¡W¡ ¢c−u m¡N¡−e¡l fl A¡W¡ ¢c−u m¡N¡−e¡l fl
q−h paÉ¡ue Ll−a q−h paÉ¡ue Ll−a q−h
Affix applicant’s Affix applicant’s
Father’s photograph Mother’s photograph
Affix the photograph f¡p−f¡−
f¡p−f¡−VÑl A¡−hce glj here and attest on the here and attest on the
here and attest on the photo photo
photo Passport Application Form
−Lhmj¡œ Af¡Êçhuú A¡−hceL¡l£l −r−œ
Ef−l¡š² R¢hàu BhnÉLz

a¡lL¡ (*) ¢Q¢q²a œ²¢jL ew …−m¡ AhnÉ f¨lZ£uz Serial numbers marked with star (*) marks must be filled in.
œ²¢jL ew 1 hÉa£a AeÉ¡eÉ œ²¢jL Cw−lS£−a (Capital Letter) f¨lZ£uz Except serial number 1 all other serials must be filled in English
(Capital Letter).

* B’¢mL f¡p−f¡VÑ A¢g−pl e¡j x ________________________________ * A¡−hc−el fÊL«¢a x ea¤e eh¡ue

Name of RPO Application type New Renew

* A¡−hceL«a f¡p−f¡−VÑl fÊL«¢a x p¡d¡le A¢g¢pu¡m L¤V¯e¢aL

Type of passport applied for Ordinary Official Diplomatic

* f¡p−f¡VÑ ¢hal−Zl fÊL«¢a p¡d¡le Sl¦l£

Type of delivery Regular Express

1z A¡−hceL¡l£l e¡j (h¡wm¡u) x ________________________________________________________________

Name of Applicant (in Bengali)

2z* A¡−hceL¡l£l e¡j x _______________________________________________________________________

Name of Applicant

3z* B−hceL¡l£l e¡j - A¡f¢e f¡p−f¡−VÑ e¡j −ki¡−h ®cM−a Q¡e ®pi¡−h V¡Cf Ll¦e z p−hÑ¡µQ 38¢V Arl hÉhq¡l Ll¡ k¡−hz
Name of Applicant – Type as you want it to appear in your passport. Maximum 38 characters are allowed.
fÊbj Awn
First Part
¢àa£u Awn
Second Part
(¢hxcËx e¡−jl ®no¡wn 2u Aw−n ¢mM−a q−h Hhw 1j Aw−n HL¡¢dL Awn b¡L−m fË¢a Aw−nl j¡TM¡−e 1¢V Ol n§eÉ ®l−M f§lZ Ll−a q−h z The last
part of the name should appear in second part. Keep a blank space between two parts of the name).
4z* ¢fa¡l e¡j x _______________________________ −fn¡ x ___________________ S¡a£ua¡ x _____________
Father’s Name Profession Nationality

5z* j¡a¡l e¡j x ________________________________ −fn¡ x ___________________ S¡a£ua¡ x ____________

Mother’s Name Profession Nationality

6z ð¡j£/ Ù»£/A¢ii¡h−Ll e¡j x _______________________−fn¡ x ___________________ S¡a£ua¡ x ____________

(fÊ−k¡SÉ q−m) Spouse’s/Guardian’s Name Profession Nationality
(if applicable)

7z* SeÈÙÛ¡e (®cn J −Sm¡) x ®c−nl e¡j ___________________________ −Sm¡l e¡j ______________________
Place of Birth Country District

8z* SeÈ a¡¢lM x ¢ce j¡p hvpl

Date of Birth Day Month Year

9z* ¢mwN (¢VL (
) ¢Qq² ¢ce) x f¥l¦o j¢qm¡ AeÉ¡eÉ

Gender (Put (
) in appropriate box) Male Female Others
f¡a¡-1
10 z
[[ SeÈ pecfœ ew (k¢c b¡−L) x
Birth Identification Number
(if available)

11z S¡a£u f¢lQuf−œl ew (k¢c b¡−L) x

National Identification Number
(if available)

12z ¢VA¡CHe (k¢c b¡−L) x

Tax Identification Number (if available) - -

13z* EµQa¡ x −px¢jx C¢’

Height cm inch

14z* ¯hh¡¢qL AhÙÛ¡ (¢VL (
) ¢Qq² ¢ce) x A¢hh¡¢qa ¢hh¡¢qa ¢hfaÀ£L / ¢hdh¡ a¡m¡LfÊ¡f¹
Marital Status Unmarried Married Widower/Widow Divorced
Put (
) in appropriate box

15z* −fn¡ x _______________________________________________________________________________

Profession

16z* haÑj¡e ¢WL¡e¡ x NÊ¡j / h¡p¡ ew _____________________________ l¡Ù¹¡/hÓL ew _________________________

Present Village/House No. Road/Block No.
Address
b¡e¡ ___________________________________ X¡LOl ___________________________
Police Station Post Office

−Sm¡ __________________________________ −f¡ØV®L¡X _________________________

District Post Code

Øq¡u£ ¢WL¡e¡ J haÑj¡e ¢WL¡e¡ HLC q−m ¢VL (
)¢Qq² ¢ce

Put (
) if Permanent Address is same as Present Address

17z* ÙÛ¡u£ ¢WL¡e¡ x NÊ¡j / h¡p¡ ew _____________________________ l¡Ù¹¡/hÓL ew _________________________

Permanent Village/House No. Road/Block No.
Address
b¡e¡ ___________________________________ X¡LOl ___________________________
Police Station Post Office

−Sm¡ __________________________________ −f¡ØV−L¡X _________________________

District Post Code

18z Sl¦l£ ®k¡N¡−k¡−Nl SeÉ ®g¡e eðl x A¢gp _______________________ −j¡h¡Cm eðl _______________________
Emergency contact numbers Office Mobile No.

h¡p¡ ________________________ C®jCm ¢WL¡e¡ ______________________

Residence email

19z* h¡wm¡−cn£ e¡N¢lL−aÆl p§œ x S¸jp§−œ hwnp§−œ A¢ih¡pe ®cn£uLlZ p¤−œ

(¢VL (
) ¢Qq² ¢ce) by birth by descent Migration Naturalization
Type of Citizenship ¯hh¡¢qLp§−œ AeÉ¡eÉ, E−õM Ll¦e
Put (
) in appropriate box by marriage Others, please specify _________________________

20z ®~àa e¡N¢lL q−m e¡N¢lLaÆ fÊc¡eL¡l£ ®c−nl e¡j x _________________________ f¡p−f¡VÑ ew _________________
Name of the other country in case of dual citizenship Passport No.

f¡a¡-2
21z* f¡p−f¡−VÑl SeÉ ¢gp Sj¡ pwœ¦¡¿¹ abÉ¡hm£ (−k abÉ…−m¡ fÊ−u¡SÉ q−h) x
Fees Payment Information

hÉ¡wL ____________________________ n¡M¡ ______________________ Sj¡Lªa ¢g Hl f¢lj¡e ____________

Name of the Bank Branch Amount deposited

l¢nc ew __________________________________ a¡¢lM _______________________

Receipt/Transaction No. Date

22z f§−hÑ fÊc¡eLªa f¡p−f¡−VÑl ¢hhlZ (fÊ−k¡SÉ q−m) x

Previous passport details (if applicable)

f¡p−f¡VÑ eðl _____________________________ Cp¤Él ÙÛ¡e J a¡¢lM ________________________________

Passport No. Place and Date of Issue

f¡p−f¡VÑ f¢lhaÑ−el L¡lZ (¢VL (
) ¢Qq² ¢ce) x q¡l¡−e¡ hÉhq¡−ll Ae¤fk¤š² −ju¡c Eš£ZÑ
Reason for re apply Lost Unusable Expired
Put (
) in appropriate box

¢S¢X eðl (fÊ−k¡SÉ ®r−œ) _________________________________________ a¡¢lM ______________________

GD No. (if applicable) Date

b¡e¡l e¡j (−k b¡e¡u ¢S¢X Ll¡ q−u−R ) ___________________________________________________________

Name of the Police Station
(wet `ªt eZ©gvb cvm‡cvU© bevqb/weKí cvm‡cv‡U©i †¶‡ÎI µwgK bs 22 cÖ‡hvR¨ n‡e| Serial 22 will also be applicable for
renewal of existing passport/for issuing duplicate passport.)

AwN£L¡l e¡j¡
e¡j¡
1z A¡¢j nfb L−l hm¢R ®k A¡−hcef−œ fÊcš ph abÉ paÉ Hhw ®L¡e ¢jbÉ¡ abÉ ¢c−u b¡L−m A¡¢j A¡Ceax cäe£u qhz
2z A¡¢j A¡−l¡ fÊ¢a‘¡ Ll¢R A¡¢j/A¡j¡l p¿¹¡e h¡ ®f¡oÉ, ®k ®L¡e L¡l−Z Ai¡hNÊÙÛ q−u fs−m ¢h−cn ®b−L A¡j¡−L Abh¡ A¡j¡l ®f¡oÉ−L
®c−n fÊaÉ¡haÑe Ll¡l ®r−œ k¡ha£u MlQ f¢l−n¡−d h¡dÉ b¡Lh Hhw ¢h−c−n A¡j¡l/¢Lwh¡ A¡j¡l p¿¹¡e h¡ ®f¡−oÉl jªaɤ OV−m jl−c−ql f¢lhqe MlQ
A¡j¡l °hd Ešl¡¢dL¡l£/A¡j¡l L¡R ®b−L A¡c¡u−k¡NÉ q−hz

a¡¢lM x _____________________ A¡−hceL¡l£l/A¢ii¡h®Ll (A¡−hceL¡l£ AfÊ¡ç huú q−m)

ü¡rl h¡ ¢VfpC (Aef−eu L¡¢m−a)

paɡue
(B−hceL¡l£ S¡a£u f¢lQufœ d¡l£ e¡ q−m)

A¡j¡l ‘¡e J ¢hnÄ¡pj−a Ef−l h¢ZÑa abÉ paÉ Hhw ____________________________________ (B−hceL¡l£) _________hvpl
k¡hv A¡j¡l f¢l¢Qaz ¢a¢e A¡j¡l pjȤ−M A¡−hcef−œ ü¡rl / ¢VfpC fËc¡e L−l−Rez

paÉ¡ueL¡l£l A¡h¡¢pL ¢WL¡e¡ x ___________________________ __________________

_______________________________________________ paÉ¡ueL¡l£l e¡j J ü¡rl
a¡¢lM x ______________
f¡p−f¡VÑ/S¡a£u f¢lQu fœ ew _____________________
−V¢m−g¡e eðl (k¢c b¡−L) _______________________________ (p£m ®j¡ql)

f¡a¡-3
 f¤¢mn ®i¢l¢g−Lne
®i¢l¢g−Lne ¢l−f¡VÑ Hl SeÉ
f¤¢mn ®i¢l¢g−Lne eðl x _______________________________________________ a¡¢lM x_____________________

A¡−hceL¡l£l a−bÉl paÉa¡ k¡Q¡C x p¢WL p¢WL eu

p¢WL e¡ q−m L¡lZ (S¡a£ua¡, Q¢lœ, f§hÑ f¢lQu, CaÉ¡¢c) x ______________________________________________________

___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

__________________________________ _________________________________
f¤¢mn ®i¢l¢g−Lne fÊ¢aü¡rlL¡l£ A¢gp¡−ll ü¡rl f¤¢mn ®i¢l¢g−Lne ¢l−f¡VÑ CpɤL¡l£ A¢gp¡−ll ü¡rl
(f¤¢mn BC¢X J p£m) (f¤¢mn BC¢X J p£m)

¢e−cÑne¡
A¡−hceL¡l£−L ¢ej
¢ejÀ¢m¢Ma
¢m¢Ma c¢mm¡¢c B−hcef−œ AhnÉC pwk¤š² Ll−a q−hz
1z A¡−hceL¡l£l HL¢V l¢Pe R¢h (55 ^ 45 ¢jx¢jx) A¡L¡−ll R¢h A¡W¡ ¢c−u m¡N¡−e¡l fl paÉ¡ue Ll−a q−hz
2z AfË¡çhuú (15 hR−ll Lj) A¡−hceL¡l£l −r−®œ A¡−hceL¡l£l ¢fa¡ J j¡a¡l HL¢V L−l l¢Pe R¢h (30 ^ 25 ¢jx¢jx) R¢h A¡W¡
¢c−u m¡N¡−e¡l fl paÉ¡ue Ll−a q−hz
3z S¡a£u f¢lQufœ Abh¡ SeÈ pecf−œl g−V¡L¢fz
4z fË−k¡SÉ ®r−œ fË¡p¢‰L ®VL¢eLÉ¡m pecpj§−ql (®kje X¡š²¡l, C¢”¢eu¡l, XË¡Ci¡l CaÉ¡¢c) paÉ¡¢ua g−V¡L¢f c¡¢Mm Ll−a q−h z
5z −k pLm hÉ¢š²NZ f¡p−f¡−VÑl A¡−hcefœ J R¢h paÉ¡ue Ll−a f¡l−he x (1) pwpc pcpÉ, (2) ¢p¢V L−fÑ¡−ln−el ®jul, ®Xf¤¢V ®jul
J L¢jne¡lNZ, (3) ®N−S−VX LjÑLaÑ¡, (4) ¢hnÄ¢hcÉ¡mu ¢nrL, (5) Ef−Sm¡ f¢loc J CE¢eue f¢lo−cl ®Qu¡ljÉ¡e, (6) ®f±lpi¡l
®jul, (7) ®hplL¡l£ L−m−Sl ¢nrL, (8) ®hplL¡l£ EµQ ¢hcÉ¡m−ul fËd¡e ¢nrL, (9) °c¢eL f¢œL¡l pÇf¡cL, (10) ®f±l
L¢jne¡lNZ, (11) l¡øËu¡šÄ hÉ¡wL J ü¡ušn¡¢pa pwÙÛ¡ h¡ L−fÑ¡−ln−el ea¤e S¡a£u ®hae ®ú−ml 7j J ac¤dÑÄ ®NË−Xl LjÑLaÑ¡NZ z

1z abÉ pwNËqL¡l£ ( Af¡−lVl ) Hl e¡j, BC¢X J ü¡rl __________________________________________________

2z A¡−hce NÊqeL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl ____________________________________________________

3z f¡p−f¡VÑ Cpɤ Ae¤−j¡ceL¡l£ LjÑLaÑ¡l e¡j, BC¢X J ü¡rl _______________________________________________

4z Cp¤ÉL«a f¡p−f¡VÑ eðlx _____________________

5z f¡p−f¡VÑ ¢haleL¡l£ A¢gp¡−ll e¡j, BC¢X J ü¡rl ___________________________________________________

6z A¡−hceL¡l£l f¡p−f¡VÑ fÊ¡¢çl ü¡rl J a¡¢lM _______________________________________________________

f¡a¡-4