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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
Nationality Japanese 2 nd Nationality
(In case of dual
citizenship,
mention
the name)
N/A
Place of Birth: NAGASAKI Date of Birth: 23 rd April 1999
Country of
Birth
JAPAN ID in applicant’s
Country:
Passport
number:
TT2640231 Passport issue
Date:
12 th December 2022
Passport
validity date:
12 th December 2032 Passport Issuing
authority:
MINISTRY OF FOREIGN
AFFAIRS
Visa number: A 2444995 Visa issue date: 10 th April 2023
Visa Category: A3 Visa validity date: 10 th April 2024
Visa issuing
authority:
Embassy of the
People’s Republic
Date of
application for visa
extension
FUKO YAMAGUCHI
Female
International Manpower Development
Organization (IM) Japan
of Bangladesh,
Tokyo, Japan.
Duration of
stay in
Bangladesh
according to
visa status:
As required
Place of visa issue
From: Tokyo, Japan
Land phone
Number:
E-mail address: yamaguchi.f@imm.or.jp
Cell phone
number:
01325-681300 Date of first
arrival in
Bangladesh:
21 st January 2023
Name of the
Immigration
checkpoint
While
Arriving first
time
in
Bangladesh:
Date of last visit in
Bangladesh:
17 th April 2023
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?
Yes Number &
duration of
work permit:
1 year
WPN-09Jul2023-00008
Validity date
of
Work
Permit:
16 th April 2024 Please mentioned
the date,
if you have
applied for
extension of your
work permit:
N/A
Do you pay tax
to Bangladesh
Government
No Does your office
Activity have any
affiliation with the
offices of
Bangladesh
Government:
Yes
Are you
engaged
With any other
occupation in
Bangladesh:
No If applicant
Engaged
with other job
then
clarify of that:
No
1. Resident address in Bangladesh:
2. Your designation in your office:
3. Educational Qualification and institution’s name:
4. Employment History (in Bangladesh & Abroad):
1 st April,2022-16 th April ,2023- International Manpower Development Organization
(IM) Japan (Japan Head office) - Japanese Teacher
17 th April 2023-Currently working - International Manpower Development Organization
(IM) Japan (Dhaka Representative Office)- Japanese Teacher
6th Floor, Bureau of Manpower Employment and
Training (BMET), 89/2 Kakrail, Ramna, Dhaka-1000.
Japanese Teacher
Faculty Of Letters Comparative Culture
TSURU UNIVERSITY
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:
7. Is your spouse(S) residing with you in Bangladesh? If yes please furnish:
SL
No
Name Passport
Number
Relation With You
NAME: FUKO YAMAGUCHI
SIGN:
DATE:
Attached with Passport
No.