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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)
N/A
Place of Birth: Tokyo, Japan Date of Birth: 27 th May 1995
Country of
Birth
Japan ID in applicant’s
Country:
N/A
Passport
number:
TZ1119694 Passport issue
Date:
11 th March 2016
Passport
validity date:
11 th March 2026 Passport Issuing
authority:
Embassy of Japan in Thailand.
Visa number: A2444265 Visa issue date: 22 nd February 2023
Visa Category: E Visa validity date: 22 nd May 2023
Visa issuing
authority:
Embassy of the
People’s Republic
of Bangladesh,
Tokyo, Japan
Date of
application for visa
extension
N/A
KYOKO KURASAKI
Female Nippon Koei Bangladesh Ltd.
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: a8843@n-koei.co.jp
Cell phone
number:
+81-80-2727-9458,
01957-089854
Date of first
arrival in
Bangladesh:
3 rd November 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:
23 rd 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:
WPN-13Mar2023-00014
1 year
Validity date
of
Work
Permit:
28 th February, 2024 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:
No
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):
2019 – 2020 ： Accounting & Personal Dept., Nippon Koei Co., Ltd.
2020 – 2022 ： Senior Manager, Accounting & Management Dept., Nippon Koei Co., Ltd.
5. Travel record for the last 3 years:
"Concord Kabir Tower" Apt #8B (8th floor), 31 Rd
100, Gulshan 2, Dhaka 1212, Bangladesh
Senior Manager
Bachelor of Arts
University of Kitakyushu
Please see next page.
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 Pass port
Number
Relation With You
NAME: KYOKO KURASAKI
SIGN:
DATE:
No.