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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
Nationality Japanese 2 nd Nationality
(In case of dual
citizenship,
mention
the name)
N/A
Place of Birth: Shiga Date of Birth: 21 st October 1981
Country of
Birth
Japan ID in applicant’s
Country:
Passport
number:
TT4072282 Passport issue
Date:
20 th July 2023
Passport
validity date:
20 th July 2033 Passport Issuing
authority:
Ministry of Foreign Affairs
Visa number: A 3744186 Visa issue date: 8 th July 2024
Visa Category: E Visa validity date: 8 th October 2024
Visa issuing
Authority:
Embassy of
Bangladesh, Tokyo,
Japan.
Date of
application for visa
extension
10 th August 2024
Hiroshi Kajitani
Male Summit Bibiyana Power Company
Limited.
Duration of
stay in
Bangladesh
according to
visa status:
As Required
Place of visa issue
From: Tokyo, Japan
Land phone
Number:
E-mail address: hiroshi.kajitani@summit-
centre.com
Cell phone
number: 01787690857
Date of first
arrival in
Bangladesh:
5 th February 2024
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:
16 th July 2024
Name of the
immigration
cheek point
while
Arriving last
time
In
Bangladesh
Do
Date of enrolment
In foreigner’s
Registration office
Not Applicable
Do you
possess
Any
Work permit?
Yes Number &
duration of
work permit:
WPN-18Jul2024-00014
1 year
Validity date
of
Work
Permit:
15 th July, 2025 Please mentioned
the date,
if you have
applied for
extension of your
work permit:
Not Applicable
Do you pay tax
to Bangladesh
Government
Exempted Does your office
Activity has 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:
Not Applicable
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:
Road-96, House-8, Apartment-A3, Gulshan-2, Dhaka-
1212, Bangladesh
Deputy General Manager
Master's Degree.
Shinshu University, Japan.
Attached with Resume
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: Hiroshi Kajitani
SIGN:
DATE: