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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:
B. Sex: M C. Name of Company/Firm:
Nationality Japanese 2 nd Nationality
(In the case of dual
citizenship,
mention
the name)
N/A
Place of Birth: Kanagawa Date of Birth: 26 May 1984
Country of Birth Japan ID in applicant’s
Country:
N/A
Passport number: TR6494447 Passport issue
Date:
17-August-2016
Passport validity date: 17-August-2026 Passport Issuing
authority:
Ministry of Foreign
Affairs
Visa number: A 2445716 Visa issue date: 23-May-2023
Visa Category: E Visa validity date: 23-August-2023
Visa Issuing
Authority:
Embassy of the
People’s
Republic of
Bangladesh,
Tokyo, Japan
Date of
application for visa
extension
N/A
ATSUSHI TERADA
Male SUMMIT POWER LIMITED
Duration of stay in
Bangladesh according
to visa status:
90 days Place of visa issue
From: Tokyo, Japan
Land phone
Number:
N/A E-mail address: atsushi.terada@summit-
centre.com
Cell phone
number: +8801321160194
Date of first
arrival in
Bangladesh:
01-October-2021
Name of the
Immigration
checkpoint
While
Arriving first time
in
Bangladesh:
Hazrat Shahjalal
International
Airport Date of last visit in
Bangladesh: 30-May-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
Validity date of
Work
Permit:
29-May-2024 Please mentioned
the date,
if you have
applied for
extension of your
work permit:
N/A
Do you pay tax to
Bangladesh
Government
Yes 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):
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:
Park Road, House-34/36, Apartment-A14, Baridhara,
Dhaka, 1212, Bangladesh.
Technical Manager
Master’s Program
Electrical Engineering and Information Systems
Graduate School of Engineering
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
No.
7. Is your spouse(S) residing with you in Bangladesh? If yes please furnish:
SL
No
Name Passport Number Relation With You
NAME: ATSUSHI TERADA
SIGN:
DATE: