Form V.

2013

Visa Application Form of the Peoples Republic of China
(For the Mainland of China only)

The applicant should fill in this form truthfully completely and clearly. Please type the answer in capital English
letters in the space provided or tick () the relevant box to select. If some of the items do not apply, please type N/A or None.

Part 1: Personal Information

Last name
KHAN
1.1
Full English name
as in passport
Middle name RAHMAN

/Photo
First name MD. HABIBUR Affix one recent color passport
photo (full face, front view,
1.2 1.3 bareheaded and against a plain
Name in Chinese Other name(s) light colored background).

1.4 Sex M
F
1.5
DOB(yyyy-mm-dd) 1972-09-01
1.6
Current nationality(ies) BANGLADESHI 1.7 Former nationality(ies)

1.8 (/)
Place of birth(city, province/state,country) FARIDPUR, BANGLADESH
1.9 /
Local ID/ Citizenship number 2916255928971
1.10 / Passport/Travel document Diplomatic Service or Official
type Ordinary () Other (Please specify):

1.11
Passport number BB0897677 1.12
Date of issue(yyyy-mm-dd) 2014-08-26
1.13 1.14
Place of issue DHAKA Date of expiry(yyyy-mm-dd) 2019-08-25
/ Former/incumbent member of parliament
Businessperson
Position________________________
Company employee
/ Former/incumbent government
Entertainer
official
/ Industrial/Agricultural worker
Position________________________
1.15 Student
Military personnel
Crew member
Position________________________
Current occupation( Self-employed
s) NGO staff
Unemployed
Religious personnel
Retired
Staff of media

() Other (Please specify):

1.16 Postgraduate College

Education () Other (Please specify):
GRADUATE

MEGHNA GROUP OF INDUSTRIES +880-2-9887545
1.17 / Name Phone number
Employer/School
Address FRESH VILLA, HOUSE NO. 15, ROAD NO. 34, GULSHAN # 1, DHAKA-1212
Zip Code
1212

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1.18
Home address 159/12 kha, west Shewrapara 1.19
Zip Code 1216
1.20/
Home/mobile phone number 88-01711368304 1.21
E-mail address ecldesign1972@gmail.com
1.22 Marital status Married Single Other(Please specify):

Name Nationality Occupation Relationship

1.23
(
,)
FATIMA KHANAM BANGLADESHI HOUSEWIFE SPOUSE
Major family
membersspouse,
TAREQUE HASSAN KHAN BANGLADESHI STUDENT SON
children,parents,et
c.,may type on
separate paper

1.24

Name
MAHBUBUR RAHMAN KHAN

01922857137
Mobile phone number

BROTHER
Emergency
Contact Relationship with the applicant
1.25 Country or territory where the
applicant is located when applying for this visa DHAKA
Part 2: Travel Information
Official Visit
As resident diplomatconsul or staff of international
Tourism
organization
Non-business visit As permanent resident
Business & Trade Work
As introduced talent As child in foster care
As crew member
Transit
2.1

Major
Short-term visit to Chinese citizen or 180 Family reunion for over 180
purpose
of your visit foreigner with Chinese permanent residence status days with Chinese citizen or foreigner with Chinese
permanent residence status

Short-term visit to foreigner residing in China As accompanying family member of foreigner
due to work, study or other reasons residing in China due to work, study or other reasons
Short-term study for less than 180 days Long-term study for over 180 days
As journalist for temporary news As resident journalist
coverage
()Other (Please specify)

( 3 ) One entry valid for 3 months from the date of issue

2.2 ( 3-6 ) Two entries valid for 3 to 6 months from the date of issue

6 ) Multiple entries valid for 6 months from the date of issue

Intended number
of entries 1 ) Multiple entries valid for 1 year from the date of issue
Other (Please specify):

2.3 Are you applying for express service?

Note: Express service needs approval of Yes No
consular officials, and extra fees may apply.

2.4
Expected date of your first entry into China on this trip (yyyy-mm-dd)

2.5
Days
Longest intended stay in China among all entries

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 Date Detailed address

2.6
,

Itinerary in
China (in time
sequencemay
type on separate
paper)

2.7 Who will pay for your travel and

expenses during your stay in China?

Name

2.8 Address

Information of
inviter in China
Phone number

Relationship with the applicant

2.9
Have you ever been granted a Chinese visa? If applicable,
please specify the date and place of the last time you were granted the visa.

2.10 12 Other countries or territories

you visited in the last 12 months

Part 3: Other Information

3.1 Have you ever overstayed your visa or
Yes No

residence permit in China?
3.2 ,Have you ever been refused a visa for China, or
Yes No

been refused entry into China?
3.3 Do you have any criminal record in China or any other
Yes No

country?
3.4 Are you experiencing any of the following conditions?
Serious mental disorder
Yes
No
Infectious pulmonary tuberculosis
Other infectious disease of public health hazards
3.5 30 Did you visit countries or territories affected
Yes
No
by infectious diseases in the last 30 days?
3.6 3.1 3.5
If you select Yes to any questions from 3.1 to 3.5, please give details below.

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 3.7
If you have more information about your visa application other than the above to declare,please give details below or type on a
separate paper.

3.8 If someone else travels and shares

the same passport with the applicant , please affix their photos and give their information below.

1 2 3
Person 1 Person 2 Person 3

Information
Affix Photo Affix Photo Affix Photo
here here here

Full name

Sex

DOB(yyyy-mm-dd)

Part 4: Declaration & Signature

4.1
I hereby declare that I have read and understood all the questions in this application and shall bear all the legal consequences for the
authenticity of the information and materials I provided.
4.2

I understand that whether to issue a visa, type of visa, number of entries, validity and duration of each stay will be determined by
consular official, and that any false, misleading or incomplete statement may result in the refusal of a visa for or denial of entry into
China.
4.3
I understand that, according to Chinese law, applicant may be refused entry into China even if a visa is granted.

Applicants signature: Date (yyyy-mm-dd):

18 Note: The parent or guardian shall sign on behalf of a minor under 18 years of

Part 5If the application form is completed by another person on the

applicant's behalf, please fill out the information of the one who completes the form
5.2 Relationship
5.1 Name
with the applicant

5.3 Address 5.4 Phone number

5.5 Declaration

I declare that I have assisted in the completion of this form at the request of the applicant and that the applicant understands and
agrees that the information provided is true and correct.

/Signature /Date (yyyy-mm-dd):

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