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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 Japanese 2 nd Nationality
(In case of dual
citizenship,
mention
the name)
N/A
Place of Birth: Fukuoka Date of Birth: 10 th June 1965
Country of
Birth
Japan ID in applicant’s
Country:
N/A
Passport
number:
MJ1002990 Passport issue
Date:
10 th February 2020
Passport
validity date:
10 th February 2025 Passport Issuing
authority:
Ministry of Foreign Affairs
Visa number: A 2445550 Visa issue date: 15 th May 2023
Visa Category: E Visa validity date: 15 th August 2023
Visa issuing
authority:
Embassy of the
People’s Republic
of Bangladesh,
Tokyo, Japan
Date of
application for visa
extension
N/A
SHINJI TANAKA
Male 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: tanaka-sn@n-koei.jp
Cell phone
number:
01701-671722 Date of first
arrival in
Bangladesh:
6 th March, 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:
20 th 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:
WPN-27May2023-00007
2 Years
Validity date
of
Work
Permit:
19 th May 2025 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:
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):
NIPPON KOEI, ASSOCIATE DIRECTOR, From 1994 To 2022
NIPPON KOEI BANGLADEH, GENERAL MANAGER 2022-Continuing
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:
Unit 5-A & B, Concord Baksh Tower Plot #11-A, Road
#48, Block #CWN(A), Gulshan-2, Dhaka 1212
GENERAL MANAGER
Bachelor in Engineering
SAITAMA UNIVERSITY, FACULTY OF ENGINEERING, 1994
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: SHINJI TANAKA
SIGN:
DATE: