APPLICATION FOR DUAL NATIONALITY

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1 Embassy of Bangladesh 3510 International Dr., NW, Washington, DC, 20008, U SA TEL- (202) , Ext: 115/100 FA X (202) W EB - APPLICATION FOR DUAL NATIONALITY Please note that three (3) sets of the entire application form including attachments need to be submitted PLEASE FILL IN THREE COPIES OF THIS FROM. PLEASE TYPE OR PRINT IN BLOCK LETTERS. UNLESS OTHERWISE MENTIONED, PLEASE COMPLETE ALL ITEMS OR WRITE "N/A" (NOT APPLICABLE) ) IF NEEDED. Please attach /staple 4 copies of 40mm X 50mm (passport size photographs) taken within the last six months (two copies with the first set and one copy each with the second and third set. PLEASE DO NOT USE GLUE. 1. Name 2. Date of birth 3. Place of birth (district, in case of Bangladesh) 4. Present address (in the United States) 5. Permanent address (in Bangladesh) Street House/Apt # City State Zip code Home telephone Cell: 6.a. Name of father 9. Permanent address of father (in Bangladesh) 6.b. Place of birth of father: 7.a. Name of mother 7.b. Place of birth of mother: 8.a. Name of spouse: 8.b. Place of birth of spouse: 10. Name and address of children (Please use separate sheet, if needed) a. b. c. 11. Name and address relatives (living in Bangladesh) who can be contacted for reference (at least one): a. Relationsihip b. Relationsihip c. Relationsihip

PLEASE TYPE OR PRINT IN BLOCK LETTERS. UNLESS OTHERWISE MENTIONED, PLEASE COMPLETE ALL ITEMS OR WRITE "N/A" (NOT APPLICABLE) ) IF NEEDED.

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3 Page Particulars of properties in Bangladesh with addresss [Please attach separate sheet, if needed] 13. Date of first leaving Bangladesh 14.a. Bangladesh Passport # 14.b. Place of issue [Please attach photocopy of Bangladesh Passport] [Please attach photocopy of US Passport] 14.c. Date of issue 15. Date of acquisition of foreign citizenship 16.a. Foreign Passport # [Please attach photocopy of US naturalization certificate] 16.b. Place of issue 16.c. Date of issue 16.d. Date of expiry 17. Present occupation 18. Annual income (in US $) 21. Work address 19. Source of income [Please attach separate sheet if needed] 20. Academic or special qualification [Please attach separate sheet if needed] City State Telephone Zip code 22. Details of remittance made to Bangladesh [Please attach copies of receipts] Name of the Bank with address Account # 23. Knowledge of Bangla Read Write Speak 24. Reasons for seeking citizenship of Bangladesh 25. a. Money order # 25.b.. Issued by 25.c. Amount in US $ Declaration: I do hereby solemnly affirm and swear that the information provided in this application for dual nationality are true, correct and complete. Date FOR OFFICIAL USE ONLY. Signature of the app licant Receipt # Date Amount (US$) Observation of the Mission Received by Signature of the issuing authority Date

b. Place of issue 16.c. Date of issue 16.d. Date of expiry 17. Present occupation 18. Annual income (in US $) 21. Work address 19. Source of income [Please attach separate sheet if needed] 20.

4 DECLARATION OF ASSETS (Page 3 of the application set) 1. Name 2. Father's Name 3.a. Description of moveable assets Description Quantity/ Number Value in US $ 3.b. Description of immoveable assets Description Nature of asset Quantity (area etc.) Value in US $ I do hereby solemnly affirm and swear that the information provided above are true, correct and complete.. Date e. g. 26-Mar-1971 Signature of the applicant

) Value in US $ I do hereby solemnly affirm and swear that the information provided above are true,

5 STATEMENT OF ACTIVITIES IN THE LAST 5 YEARS (Page 4 of the application set) 1. Name 2. Father's Name 3. Description of activities Description of Activities (Education/service/business) From To I do hereby solemnly affirm and swear that the information provided above are true, correct and complete. Date e. g. 26-Mar-1971 Signature of the applicant

Description of activities Description of Activities (Education/service/business) From

6 AFFIDAVIT FOR DUAL NATIONALITY CERTIFICATE (Page 5 of the application set) I, ( name) Son of Daughter of Spouse of Present address (in the United States) Permanent address (in Bangladesh) Street House/Apt # City State Zip code Present occupation: do hereby solemnly affirm and swear that the information provided in my application for dual nationality are true, correct and complete. In witness whereof, I have signed this affidavit before the Minister Counselor/ Notary Public on the day of First Secretary Signature of the deponent (Applicant) The deponent has signed in my presence. Signature of Embassy Official or Notary Public

provided in my application for dual nationality are true, correct and complete.

7 Instruction and Requirements for Dual Nationality application Application seeking Dual Nationality should be submitted in the prescribed Form (three sets). Following may be noted during submission of the application form: a) If the applicant is a person temporarily residing in Bangladesh, the application shall be submitted directly to the Government of Bangladesh (Ministry of Home Affairs); b) If the applicant lives in a foreign country, the application should be sent through the Bangladesh Diplomatic Mission/ Consulate to that country; and c) Where there is no Bangladesh Mission or Consulate in a country of applicant s residence, the application may be sent through Bangladesh Mission or Consulate in the country nearest to that country. Each application set shall be accompanied by: 1. Affidavit affirming the truth of the statement made in the application and signed before the Minister/Counselor/First Secretary / Notary public/ or persons of equivalent status of the Embassy of Bangladesh in Washington DC (please see page 5) 2. Documentary evidence regarding remittances to Bangladesh for last 3 years. 3. Copy of foreign citizenship certificate or Naturalization Certificate 4. Declaration of assets (Movable / Immovable) in Bangladesh (please see page 3). If required please use a separate sheet. Statement of Parent's assets should be given if the applicant does not have any asset in his /her name. 5. Statement of activities for past 5 years (service, education, business etc.) since first departure from Bangladesh (Please see page 4). Please use separate sheet if required color recent passport size photograph (print name on the back ) 7. Fee: Money order of certified check of the amount of US payable to the Embassy of Bangladesh.

Bangladesh (Ministry of Home Affairs); b) If the applicant lives in a foreign country, the application should be sent through the Bangladesh Diplomatic Mission/ Consulate to that country; and c)

8 8. Copy of Birth Certificate of children born in the USA (if she/he is the applicant). 9. Copy of Parent's Bangladesh Passport (page 1-7) or Dual Citizenship Certificate in the case of child applicant born in the USA. 10. Photocopy of Bangladesh passport page (1-7).

APPLICATION FOR DUAL CITIZENSHIP. File No. CITIZENSHIP ACT (CHAPTER 349 )

APPLICATION FOR DUAL CITIZENSHIP (For office use only) Registration 23A Form "S" File No. Certificate No. To be completed in "BLOCK CAPITALS" Please follow instructions on page 7 & 8 before perfecting