Security Clearance
Form-2
(To be filled by applicant)
Reference:
Subject: Personal Information.
Please find the information furnished here under for your ready reference.
KOTARO TAKEUCHI
a I Name:
NICCA CHEMICAL CO., LTD.
Male
b I Sex: M C. Name of company/firm C.
Nationality
Japanese
2nd Nationality
(In case of dual citizenship,
mention
the name)
No
Place of Birth:
FUKUI
Date of Birth:
09 August, 1980
Country of Birth
Japan
ID in applicant’s
Country:
N/A
Passport number:
TT1404083
Passport issue
Date:
30 August 2021
Passport validity date:
30 August 2031
Passport Issuing authority:
Ministry of Foreign affairs, Japan
Visa number:
A 2340768
Visa issue date:
10 September 2021
Visa Category:
Employment
Visa validity date:
10 December 2021
Visa issuing authority:
Embassy of the People's Republic of Bangladesh
Embassy,Tokyo,
Japan
Date of
application for
visa extension
12/12/2021
Duration of stay in Bangladesh according to
visa status:
90 days
Place of visa issue
From:
Agargoan, Dhaka
Land phone
Number:
E-mail address:
ko-takeuchi@niccachemical.com
Cell phone
number:
+88 01735901417
Date of first
arrival in
Bangladesh:
18 October 2021
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:
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-26Oct2021-00012
1 (One) year
Validity date of
Work
Permit:
17 October 2022
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
Suvastu Gafur Riz Garden, House No # 96,
Resident address in Bangladesh:
Flat No # 10B, Road No # 23, Block # A, Banani, Dhaka – 1213
General Manager
2. Your designation in your office:
Bachelor of Economics
3. Educational Qualification and institution’s name:
FUKUI PREFECTUAL UNIVERSITY
4. Employment History (in Bangladesh & Abroad):
In Bangladesh, Hong Kong Nicca chemical ltd. Technician Expert (chemical) 2016 to 2021
In Japan, Nicca chemical ltd. Co., LIMITED. (Technician Expert) _Chemical Department From 2010 to 2015
In USA, NICCA USA INC. (Sales Promoter) 2007 to 2010
In Japan, NICCA CHEMICAL CO., LTD. (Sales Promoter) 2004 to 2007
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
NAME: KOTARO TAKEUCHI
SIGN: √
DATE: