Security Clearance
Form-2
(To be filled by applicant)
Reference:
Subject: Personal Information.
Please find the information furnished here under for your ready reference.
TAKUYA WAKUTSU
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:
05 February, 1971
Country of Birth
Japan
ID in applicant’s
Country:
Passport number:
TS0999060
Passport issue
Date:
18 June, 2018
Passport validity date:
18 June, 2028
Passport Issuing authority:
Ministry of Foreign Affairs Japan
Visa number:
A1135392
Visa issue date:
12 June, 2019
Visa Category:
A3
Visa validity date:
11 June, 2023
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:
Cell phone
number:
018-4719-8852
Date of first
arrival in
Bangladesh:
20 June, 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:
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-01Jul2019-00001
2 (Two) years
Validity date of
Work
Permit:
19 June 2021
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
Road-Park, House-25, Apt-A4, Baridhara, Dhaka-1212,
Resident address in Bangladesh:
Bangladesh.
General Manager
2. Your designation in your office:
Master of Science in Engineering
3. Educational Qualification and institution’s name:
KEIO UNIVERSITY
Nippon Signal Company Limited
4. Employment History (in Bangladesh & Abroad):
In Bangladesh from 20 June 2019 to Present;
In Japan Ministry of Land, Infrastructure, Transport and Tourism, Railway Bureau, (Deputy Director) April, 2013 to March, 2016
In Japan Nippon Signal (General Manager) April, 2016 to till now.
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: TAKUYA WAKUTSU
SIGN:
DATE: