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Security Clearance
Form-2
(To be filled by the applicant}
Reference:
Subject: Personal Information.
Please find the information furnished here under for your ready reference.
A. Name: ATSUSHI TERADA
B. Sex: I Male C. Name of Company/Firm: I SUMMIT POWER LIMITED
Nationality Japanese 2 nd Nationality NIA
(In the case of dual
citizenship,
mention
the name)
Place of Birth: Kanagawa Date of Birth: 26 May 1984
Country of Birth Japan ID in applicant's NIA
Country:
Passport number: TR6494447 Passport issue 17-August-2016
Date:
Passport validity date: 17-August-2026 Passport Issuing Ministry of Foreign
authority: Affairs
Visa number: A 2445716 Visa issue date: 23-May-2023
Visa Category: E Visa validity date: 23-August-2023
Visa Issuing Embassy of the Date of NIA
Authority: People's application for visa
Republic of extension
Bangladesh,
Tokvo,Jaoan
Duration of stay in 90 days - Place of visa issue
Bangladesh according From: Tokyo,Japan
to visa status:
Land phone NIA E-mail address: atsusbi.terada@summit-
Number: centre.com
Cellphone Date of first 01-October-2021
number: +8801321160194 arrival in
Bangladesh:
Name of the Hazrat Sbahjalal
Immigration International
checkpoint Airport Date of last visit in
While Bangladesh: 30-May-2023
Arriving first time
in
Bangladesh:
Name of the Date of enrolment NIA
immigration cheek In foreigner's
point while Do Registration office
Arriving last time
In Bangladesh
Do you possess Yes Number&
Any duration of 1 Year
Work permit? work permit:
Validity date of 29-May-2024 Please mentioned NIA
Work the date,
Permit: if you have
applied for
extension of your
work permit:
. Do you pay tax to Yes Does your office NIA
Bangladesh Activity have any
Government affiliation with the
offices of Bangladesh
Government:
Are you engaged N o If applicant NIA
With any other Engaged
occupation in with other job
Bangladesh: then
clarify of that:
1. Resident address in Bangladesh: Park Road, House-34/36, Apartment-A14, Baridhara,
Dhaka, 1212, Bangladesh.
2. Your designation in your office: Technical Manager
I Master's. Program
3. Educational Qualification and institution' s name: .
Electrical Engineering andlnformation Systems
4. Employment History (in Bangladesh & Abroad):
5. Travel record for the last 3 years:
Chubu Electric Power Co., Inc.
-Member 2015-2016
-Operator 2013-2015
-Engineer 2010-2012
JERA Co., Inc.
-Manager 2020-Present
-Assistant Manager 2016-2020
Attached with Passport ·
6. Are you engaged with any social/ cultural activities apart from your present occupation in
Bangladesh? If yes please provide details:
N o.
7. Is your spouse(S) residing with you in Bangladesh? If yes please furnish :
SL Name Passport Number Relation With You
No
NAME: ATSUSIIl TERADA
SIGN:
DATE: 17 . off, 2023