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Security Clearance
Form-2
(To be filled by applicant)
Reference:
Subject: Personal Information.
Please find the information furnished here under for your ready reference .
a I Name:
b I Sex: M C. Name of company/firm C.
Nationality Japan 2 nd Nationality
(In case of dual
citizenship,
mention
the name)
No
Place of Birth: SAITAMA Date of Birth: 31 October 1983
Country of
Birth
Japan ID in applicant’s
Country:
N/A
Passport
number:
TT1887629 Passport issue
Date:
28 October 2021
Passport
validity date:
14 March 2029 Passport Issuing
authority:
Ministry of Foreign Affairs, Japan
Visa number: A2342406 Visa issue date: 05 March 2022
Visa Category: FE Visa validity date: 10 June 2022
Visa issuing
authority:
Embassy of
Bangladesh, Tokyo,
Japan
Date of
application for
visa extension
16 May 2022
Duration of
stay in
Bangladesh
according to
visa status:
As Required Place of visa issue
From:
Tokyo. Japan
Land phone E-mail address: tomokazu.nitta@fujita.co.jp
YUKA NITTA
Female
Number:
Cell phone
number:
+880-1323-878-586 Date of first
arrival in
Bangladesh:
29 March, 2022
Name of the
Immigration
checkpoint
While
Arriving first
time
in
Bangladesh:
Hazrat Shahjalal
International
Airport, Dhaka.
Immigration police,
Bangladesh.
Date of last visit in
Bangladesh:
29 March, 2022
Name of the
immigration
cheek point
while
Arriving last
time
In
Bangladesh
Do
Date of enrolment
In foreigner’s
Registration office
N/A
Do you
possess
Any
Work permit?
N/A Number &
duration of
work permit:
N/A
Validity date
of
Work
Permit:
N/A
Please mentioned
the date,
if you have
applied for
extension of your
work permit:
N/A
Do you pay tax
to Bangladesh
Government
N/A Does your office
Activity have any
affiliation with the
offices of
Bangladesh
Government:
N/A
Are you
engaged
With any other
occupation in
Bangladesh:
No If applicant
Engaged
with other job
then
clarify of that:
N/A
1. Resident address in Bangladesh:
2. Your designation in your office:
3. Educational Qualification and institution’s name:
4. Employment History (in Bangladesh & Abroad):
Flat: 5A, Fifth Floor, House No. 19,
Road: Park Road, Baridhara, Dhaka-1212.
5. Travel record for the last 3 years:
6. Are you engaged with any social/ cultural activities apart from your present occupation in
Bangladesh? If yes please provide details: No
7. Is your spouse(S) residing with you in Bangladesh? If yes please furnish:
SL
No
Name Pass port
Number
Relation With You
1. Mr. Tomokazu Nitta TT1887648 Husband
NAME: Yuka Nitta
SIGN:
DATE: