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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.
MATSUOKA KOZO
a I Name:
NICCA CHEMICAL CO., LTD.
Male
b I Sex: M C. Name of company/firm C.
Nationality
Japan
2nd Nationality
(In case of dual citizenship,
mention
the name)
N/A
Place of Birth:
Ibaraki
Date of Birth:
23rd February 1970
Country of Birth
Japan
ID in applicant’s
Country:
N/A
Passport number:
TZ1387565
Passport issue
Date:
11th November 2011
Passport validity date:
11th November 2029
Passport Issuing authority:
Embassy of Japan in Indonesia
Visa number:
A 3753572
Visa issue date:
14th January 2026
Visa Category:
E visa
Visa validity date:
14th April 2026
Visa issuing authority:
Tokyo, Japan
Date of
application for visa extension
N/A
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:
k-matsuoka@niccachemical.com
Cell phone
number:
Date of first
arrival in
Bangladesh:
08th November 2025
Name of the Immigration checkpoint
While
Arriving first time
in
Bangladesh:
Hazrat Shahjalal International Airport, Dhaka. Immigration police, Bangladesh.
Date of last visit to Bangladesh:
21st January 2026
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-26Jan2026-00012
Validity date of
Work
Permit:
20th January 2027
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 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 jobs
then
clarify that:
No
Apartment-10B on the 10th Floor of GAFUR Riz Garden, House No. 96, Road No. 23, Block-A, Banani, Dhaka-1213
.
Resident address in Bangladesh:
General Manager
Your designation in your office:
Faculty of Commerce
Educational Qualification and institution’s name:
Doshisya University
Attached with Resume
Employment History (in Bangladesh & Abroad):
5. Travel record for the last 3 years:
Attached with Passport
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
Passport Number
Relation With You
NAME: MATSUOKA KOZO
SIGN:
DATE: