AccessAcademy2009-10Application_001

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Admissions Office Asian University for Women20/A M.M. Ali RoadChittagong

–

4000, BangladeshE-mail:admissions@a

uw.edu

.

bd

Web: www.asian-university.org

ACCESS ACADEMY APPLICATION FORM

The information you provide in this form will be used only for screening your application for an entrance examination and personal interview.

A. PERSONAL DETAILS

1. Name of Applicant

________________________________________________________

Last /Family First Middle

2. Date of Birth

____________________________

Day Month Year

3. Place of Birth

: ________________________________________________________

City/Town/Village State/ Province Country

4.

Nationality

___________________________________

5. Religion (optional)

Islam

Hinduism Buddhism Christianity

A second copy of the photo must be

Other

attached

to the supplementary

Identification Form

, included with this

6. Ethnicity (optional) ___________________________________________________

application.

7. Current Mailing Address

Address ____________________________________________________

House Number Street Name / Number

City/Town/Village ____________________________________________________ State/Province/District ____________________________________________________ Country ____________________________________________________ Postal Code (if any) ____________________________________________________ Phone Number(s) ____________________________________________________ Fax Numbers ____________________________________________________ Email Address ____________________________________________________

B. FAMILY DETAILS

8. Father

’

s Name:

________________________________________ 9. Mother

’

s Name: _______________________________________

Father

’

s Present Occupation

________________________________

Mother

’

s Present Occupation ___________________________

Father

’

s Educational Qualification ______________________________ Mother

’

s Educational Qualification ____________________________

Please affix here a passport- size photograph of the applicant.

This form must be completed and sent to the recruitment coordinator by

the following dates: Feb. 5, 2009: Bangladesh, Cambodia, India, Nepal, Sri Lanka; Feb. 19:

all other countries. Coordinators' addresses are

listed on the last page of this form.

2

10. Siblings (Brothers/Sisters)

Name Age If in school, please specify level/class; If schooling iscomplete, then specify highest educationalattainmentIf working, please givename of job

Sisters: ____________________

________________

_______ _______________________ _____________________

____________________

________________

_______ _______________________ _____________________

____________________

________________

_______ _______________________ _____________________

____________________

________________

_______ _______________________ _____________________

Brothers: ____________________

_______________

_______ _______________________ _____________________

____________________

_______________

_______ _______________________ _____________________

____________________

_______________

_______ _______________________ _____________________

____________________

_______________

_______ _______________________ _____________________

11. Monthly Income of the Family

Currency _______________________ Amount __________________________

e.g. Bangladesh Taka

C. KNOWLEDGE AND SKILLS

12. Schools and Colleges Attended

Name of School/CollegeMedium of Instruction(English or Other Language) Years AttendedFrom To13. Marks/Grades secured in your previous public/government examination

Name of Examination:________________________________________

(Please attach certified copies of examination/relevant certificates)

Subject

Marks (%) / Grades

School/State Ranks

(if you have any) e.g.

1

st

,2

nd

, 3

rd

, or 1

st

Division, 2

nd

Division, etc.

English

Other Language (specify)

Math

Science

Social Science

Others: (specify) i.

ii.

iii.

3

iv.

v.

14. Computer Literacy

Can you use a computer? Yes No If yes, are you able to use the following? Word processing good fair do not know Excel spreadsheet good fair do not know Internet good fair do not know

15. Extracurricular Activities:

Provide details of your other skills/activities outside class (if any)

e.g. Sports, Dance, Music, Painting, etc.

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

16. Leadership positions in school groups:

(if any)

e.g. class monitor, group leader for activities, team leader in Girl Guides, etc.

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

17. Awards, Prizes, and Scholarships:

Briefly list or describe any awards, prizes, or scholarships that you have received at any time in your life.

Name of the Award/Prize Year Why did you get it? Who gave it to you?

18. Community Activities and Service

Have you ever been involved in activities to help people in your community?

Yes No

If so, please describe below what you did. e.g. flood relief, local fair, community events, picnics, etc.

________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

19. Have you stayed away from home before for your studies?

Yes No

If yes, for how long? ______ years

20. What is the farthest distance you have traveled from your home? _____

kms.

21. How did you learn about the Asian University for Women? (

Check all that apply.)

Country coordinator TV Newspaper Radio Internet Other: _______________________

22. How much can your family pay each year for your education? ________________________________

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