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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.
TOSHIHIRO NAKAYAMA
a I Name:
Nippon Signal Company Limited
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:
Saitama, Japan
Date of Birth:
01 July, 1962
Country of Birth
Japan
ID in applicant’s
Country:
N/A
Passport number:
TK4732388
Passport issue
Date:
08 July, 2011
Passport validity date:
08 July, 2021
Passport Issuing authority:
Ministry of Foreign Affairs Japan
Visa number:
A1137226
Visa issue date:
12 September, 2019
Visa Category:
A3
Visa validity date:
08 January, 2021
Visa issuing authority :
Embassy of The People’s Republic of Bangladesh, Tokyo, Japan
Date of
application for
visa extension
N/A
Duration of stay in Bangladesh according to
visa status:
As required
Place of visa issue
From:
Tokyo, Japan
Land phone
Number:
E-mail address:
nkym-ts@signal.co.jp
Cell phone
number:
+880 1870 479180
Date of first
arrival in
Bangladesh:
22 September, 2019
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:
30 September, 2019
Name of the
immigration cheek point while
Arriving last time
In
Bangladesh
Do
Date of enrolment
In foreigner’s
Registration office
Do you possess
Any
Work permit?
Yes
Number &
duration of
work permit:
WPN-04Oct2019-00001
2 (Two) years
Validity date of
Work
Permit:
Two years from
22 September 2019
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:
Yes
Are you engaged
With any other
occupation in Bangladesh:
No
If applicant
Engaged
with other job
then
clarify of that:
N/A
Park Road, House-25, Apt-A4, Baridhara, Dhaka 1212
Resident address in Bangladesh:
Manager
2. Your designation in your office:
3. Educational Qualification and institution’s name:
Nippon Signal Company Limited
4. Employment History (in Bangladesh & Abroad):
In Bangladesh from 22 September 2019 to Present;
In Japan Design and development manager for PSD System 1990 to 2005
In Japan Manager Nippon Signal, April-2005 to till date
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: TOSHIHIRO NAKAYAMA
SIGN:
DATE: