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People's Republic of Bangladesh
MRV
Delivery
Slip -
DHAKA
LrtrOltl)Clll
l),:L_;_i11J;
Countc-1 l)c;po~11
l).;te
Call Date
Application Type
Purpose
Of
v,s,t
I HSI Name
la~:
Norn<!
First
Name
on
Visa
Last
Name
on
Visa
Date of B1rtll
l'rc,;ent Nat,on.-llity
Contact r,1,1noer(l-'ermanent) (,onto.1cI
Numoer(Bangladesh)
f>e:rmanent Address
1510911964
JPN - Japanese
MALE
817089992782
01729201902
32-6, SAKURA 3-CHOME, SETAGAYA-KU, TOKYO
1560053, JAPAN ..
/\ddrcss
Ill
Bangladesh FLAT 6C, HOUSE# 50, PARK ROAD, BARIDHARA,
DHAKA,.
v,sa Printed Date
l~e:cc,ved By
v,sa No
Passport Number
Number
of
Entries
Fee
Fee Receipt
Over Stay Fees
Over
Stay
Receipt Number
Ill lllllllllllllll
lllllllllllllllllHIIIIII
I
ii
2601V0000642107
TM1946084
MULTIPLE
~ Operator's Signature
Applicant's Signature