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 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: Chiba Date of Birth: 6 th April, 1981
Country of
Birth
Japan ID in applicant’s
Country:
N/A
Passport
number:
TZ2133797 Passport issue
Date:
2 nd August, 2022
Passport
validity date:
2 nd August, 2032 Passport Issuing
authority:
Embassy of Japan in Thailand
Visa number: A 2100620 Visa issue date: 14 th March, 2024
Visa Category: E Visa validity date: 14 th June, 2024
Visa issuing
authority:
Embassy of the
People’s
Republic of
Bangladesh
Bangkok
Date of
application for visa
extension
N/A
KENJI TAKEDA
Male
MIURA BANGLADESH CO.,
LTD.
Duration of
stay in
Bangladesh
according to
visa status:
As Required
Place of visa issue
From: Bangkok, Thailand
Land phone
Number:
N/A E-mail address: takeda_kenji@miuraz.co.jp
Cell phone
number:
01332-567790 Date of first
arrival in
Bangladesh:
31 st January, 2024
Name of the
Immigration
checkpoint
While
Arriving first
time
in
Bangladesh:
Hazrat Shahjalal
International
Airport. Date of last visit in
Bangladesh:
26 th March, 2024
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-30Mar2024-00004
> 2 years
Validity date
of
Work
Permit:
25 th March, 2026 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):
Period Organization Position
December 2007 Miura Protech Co., Ltd. in the Techno
Tokyo Maintenance Area.
April 2008 Miura Kogyo Co., Ltd.
December 2011 Saitama Sales Office
April 2014 Moved to the Nishi Saitama Branch and
joined the Kawagoe Sales Office. Member
April 2015 Nishi Saitama Branch and continued
working at the Kawagoe Sales Office. Maintenance Chief.
House # 08, Road # 06, Apartment #302, Baridhara
Diplomatic Zone. Dhaka-1212, Bangladesh.
General Manager
Bachelor in Department of Systems
Engineering.
Nippon Institute of Technology.
April 2019
Thailand Representative Department at
MIURA INDUSTRIES (THAILAND) CO.,
LTD.
Chief
June 2020 Thailand Representative Department, at
MIURA INDUSTRIES (THAILAND) CO.,
LTD.
Section Chief
June 2021 Thailand Representative Department, at
MIURA INDUSTRIES (THAILAND) CO.,
LTD.
Manager
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: KENJI TAKEDA
SIGN:
DATE:
Attached with Passport
No.