TEL - (212) 599 6767, (646) 645 7242 FAX - (212) 682 9211 ...

CONSULATE GENERAL OF BANGLADESH

34-18 Northern Boulevard (Ground Floor), Long Island City, NY - 11101, USA TEL - (212) 599 6767, (646) 645 7242 FAX - (212) 682 9211 E-MAIL: contact@, WEB -

APPLICATION FOR ATTESTATION /

CERTIFICATION

PLEASE TYPE OR PRINT IN BLOCK LETTERS. PLEAE CHECK (X) THE APPROPRIATE BOX

Service requested for

Attestation of documents Certification of birth

Other certificates.

Please specify

1. Name of applicant 3. Nationality at birth

2. Date of birth 4. Passport #

(e. g. 26-Mar-1971)

Applicants having Bangladeshi nationality at birth must present his/her Bangladesh passport details at Sl Nos. 3,4, 5, 6, 7, 8, 9 and 11.

5. Place of issue 8. Name of father

6. Date of issue (e. g. 26-Mar-1971)

9. Name of mother

7. Date of expiry

(e. g. 26-Mar-1971)

10. Sex

Male

12. Present address

Female

11. Marital status

Single

Married

Widow/Widower

13. Permanent address in Bangladesh

Divorced

Street

Village:

House/Apt #

Post Office

City

Thana/Upazila

State

Zip

District

Home Tel:

Cell:

14. Service Priority

Ordinary

Urgent

15. Declaration

I declare that information given on this applicaiton is true, correct and complete and documents presented herewith for attestation / certification are genuine. I understand that I am responsible for retaining these documents and present it to appropriate authorities upon demand.

Date

[e. g. 26-Mar-1971]

16a. Money order #

FOR OFFICIAL USE ONLY

Signature of the applicant 16. b. Issued by

16 c. Amount in US $

Receipt # Mode of Service Comments:

Mail-In

Date Walk-In

[e. g. 26-Mar-1971] Received by

Amount (US$) Processed by

Signature of the issuing authority

BDCGNY-ATTESTATION-09 (01-2015) E

Date

[e. g. 26-Mar-1971]

This form can be filled electronically. Please visit to download a copy.

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