D.I.P.

- 4
VISA APPLICATION FORM

To

(1) The Director General,

Department of Immigration & Passports A copy of
Government of Bangladesh, Dhaka. photograph to be
affixed here.
(2) The Assistant Director,
Regional Passport Office
..................................................

Dear Sir,
I shall be grateful if a Multiple/Entry/Re- entry/ Extension of Visa is granted to me. My full
particulars are as follows:

NOTE: 1. All the columns should be filled in properly.

2. If any of the particulars furnished below is found to be incorrect of information withheld
the visa/extension of stay is liable to be cancelled at anytime.

1. Name in full (Surname in Capital) ................................................................................................................

2. (a) Permanent address ..................................................................................................................................
(b) Present address in Bangladesh ................................................................................................................
.................................................................................................................................................................

3. Date of
birth ....................................................................................................................................................
4. Place of birth (Country, Town and
District) ...................................................................................................
..........................................................................................................................................................................
5. Present Nationality ......................................................................................................................................
6. Nationality at birth .........................................................................................................................................
7. Name of father/ husband with his nationality ................................................................................................
8. Whether holder of a passport from his/her government ................................................................................
9. Passport No ............................................... Date of issue ...............................................................................
Place of issue ............................................. Date of Expiry ...........................................................................

10. Profession/Occupation (give detail) :

(a) Business (Nature & detail) ......................................................................................................................
(b) Employment : Name of Organisation ......................................................................................................
Capacity in which employed ............................................................................................
(c) Annual income/salary ..............................................................................................................................
11. Whether previously visited Bangladesh and, if so, place of residence with dates and the purpose of
previous visits ...............................................................................................................................................
.......................................................................................................................................................................
12. If working in Bangladesh, details of employment are to be given :
(a) Name and address of the organization .................................................................................................
 (b) Capacity in which employed ................................................................................................................
(c) Terms of employment ..........................................................................................................................

(d) Period of employment with date ...........................................................................................................

(e) Monthly salary ......................................................................................................................................
(f) Whether income tax payee ....................................................................................................................
(If the reply is yes, receipts of income-tax payment for the last two years should be attached.
If not, necessary reasons for nonpayment to be stated.)

13. Period and purpose for which Entry/Re-entry/Multiple entry/Extension of Visa is required :
(a) Period ........................................................................
(b) Purpose ......................................................................

14. For applicant of Multiple/Re-entry visa only :

(a) Name of country to which applicant is proceeding and purpose of journey ........................................
...............................................................................................................................................................
(b) Purpose of return to Bangladesh ..........................................................................................................
(c) Period of stay in Bangladesh after Re-entry ........................................................................................

NOTE : Extension of transit visa which is valid for a fortnight will not generally be granted.

15. Date of last arrival in Bangladesh .................................................................................................................

16. Last Visa number with date and the name of the Visa issuing authority.

17. Name and address of persons in Bangladesh who will furnish information as to the applicant and also
furnish financial guarantee for maintenance and repatriation if necessary.

1. (a) Name and address 2. (a) Name and address

..................................................... ......................................................
..................................................... ......................................................
..................................................... ......................................................
(b) Profession/Occupation (b) Profession/Occupation
..................................................... ......................................................
(c) Annual income .............................. (c) Annual income .............................
(d) Whether income-tax payee (d) Whether income-tax payee
....................................................... ......................................................
If the reply is yes, receipts of income tax payment for the past two years should be attached.
18. Date on which present permission of stay in Bangladesh expire ..................................................................
........................................................................................................................................................................

19. Remarks, if any .............................................................................................................................................

Dated .......................... 20...........

..................................................
(Full signature of the applicant)
Printed from the e-Citizen application of the Government of Bangladesh Download site: http://www.forms.gov.bd