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Albukhary International University

FOUNDATION STUDIES ENROLMENT & SCHOLARSHIP APPLICATION FORM

(KPT/JPS/DFT/US/K03)

A. PERSONAL DETAILS

Name as stated in the Identity Card/Passport (in capital letters): MOHAMMOD ALI Gender: MALE Citizenship: BANGLADESHI Date of Birth: 03-02-1994 Age: 16 Marital Status: SINGLE Country/State of Origin: BANGLADESH Identity Card/ International Date of Expiry: NO NEED TO WRITE Date of Issue: N.N Passport No: N.N Place of Issue: N.N Country of Residence:BANGLADESH Religion: ISLAM

Religious Denomination/Madzhab (Muslim only): N.N Ethnic Origin (Malaysian only): N.N

# Mailing Address Street: BAZARPARA, KOTCHANDPUR, JHENIDAH. City/State: KHULNA Telephone No: 01725399935 Country: BANGLADESH Postcode: 307 Fax No: N.N Email Address: alimohammod62@yahoo.com

# Permanent Address (if different than above) Street: SAME City/State: S. Telephone No: S. Country: S. Postcode: S. Fax No: N.N

B. FAMILY DETAILS Name of Father/Guardian:FATHER S NAME Identity Card/Passport: N.N Citizenship: BANGLADESHI LIVING

Occupation: BUSINESS Monthly Income*: 2OOO (USD or RM) No. of Dependents: Telephone No: 01730170032 Fax No: N.N Address: SAME

Name of Mother: MOTHER S NAME Identity Card/ Passport No: N.N Citizenship: SAME

LIVING

Occupation: HOUSEWIFE Monthly Income*: N.N (USD or RM) No. of Dependents: Telephone No: 01732-626428 Fax. No: N.N Address: SAME * You are required to submit relevant documents as proof of evidence.

# Number of brothers and sisters in the family Name: FATHEMA Age: 20 Relationship: SISTER

Marital STATUS: SINGLE School/college/university: K.KAMIL.MAD. Occupation: STUDENT Income: N.N

C. REFEREES (For International Applicants Only) Name: MD.JOYNAL ABEDIN. (ANY TEACHERS NAME) Email: HIS E-MAIL. Tel: H.TEL.NO.

NAME: ANOTHER TEACHERS NAME Email: S.

Tel: S.

D.LIST OF ALL SCHOOLS ATTENDED AND QUALIFICATIONS/DIPLOMA/CERTIFICATE OBTAINED* (Beginning from Primary Level) NAME OF SCHOOL: KOT.KAMIL.MAD. Location/STATE/COUNTRY: KOTCHANDPUR DATE OF Entry: 03-08-1999 DATE OF Exit: 25-03-2009 TYPE OF CERTIFICATE OBTAINED: SCHOOL CERTIFICATE Score/Grade/GPA/DIVISION: GPA.5 * Please submit certified copies of the original certificates/documents and transcripts

E. EXTRA-CURRICULAR ACTIVITIES/COURSES ATTENDED** List your school/community/religious/sport/other activities/courses attended in the past three (3) years. Activities: N.N Position held or honours : N.N From: N.N To: N.N ** Please submit certified copies of the original certificates/documents

F. ADDITIONAL INFORMATION i. Have you ever studied in any institution of higher learning in Malaysia? #NO Name and address of the institution(s): N.N iii. Reasons for leaving: N.N Study/Course completed: N.N

If Others, please state: N.N iv. Transfer of Credit (please refer to guidelines to complete the application form) N.N Do you know how to apply for transfer of credit? N.N v. Medical Disclosure Do you have any disability, impairment or long-term medical condition which may affect your studies? N.N If you do, you need to specify or tick ( ) the relevant boxes. N.N

Vi. Emergency Contact Title: MOHAMMOD ALI Relationship: BROTHER Mobile no : 0169673748 Home phone: N.N Office phone:N.N Others: N.N

G.PERSONAL STATEMENT

Please write an essay (in English) of approximately 100 - 150 words, which will provide us withinformation about you that is not requested elsewhere in the AIU Application for admission. We areinterested in learning about your educational goals and aspirations, your achievements and honours, youracademic background, your special interests and experiences, your reasons for applying for the Albukharyscholarship and anything else that you would like us to know about you.

WRITE ABOUT THE TOPICS

H. DECLARATION

I hereby attest that I have personally filled in this Application Form and the information contained herein iscomplete and accurate to the best of my knowledge. I understand that withholding or giving falseinformation will make me ineligible for admission and future enrolment. I further understand that I may berequired to appear for an interview or to undergo such test as requested by the University as a condition foradmission to the programme of study for which I have applied. Applicant s Signature: MOHAMMOD ALI Date: 01-01-2011

CHECKLIST

Please submit all the following items along with the Application Form to ensure that your application is complete and can be processed for admission. Please tick ( ) in the appropriate boxes to indicate items thathave been attached. i.Certified copies of National Identification/passport or any authorised identification. ZATIO PORYCHOYPOTRO ii.Certified copies of Cambridge GCE O Level/A Level, SijilPelajaran Malaysia (SPM)/(STPM), or any other equivalent certificates. DAKHIL CERTIFICATE iii.Certified copies of School Leaving Certificate/References. SCHOOL TRANSFER CERTIFICATE iv.Recommendation Letter (for international applicants only). CHARITRIK SONOD FROM PRINCIPAL OF MADRASA v.4 recent passport-size, colour photographs.

vi.University Entrance Exam (compulsory for countries which require students to pass the Entrance Exam for entry into the University in their respective countries).

vii. Financial Statement/Confirmation of parent s income. INCOME SONOD FROM POUROSOVA viii. Certified copies of any other relevant documents i.e. Death Certificate of Parent(s), co-curriculum activities etc. Important: Please submit only certified photocopies of official documents. If the documents are not in English, certified English translation must be attached. Please note that all application forms will be disposed of six months after the closing date.

Upon completion, please return this form to:

Registrar, Admissions and Records, Albukhary International University, JalanTun Abdul Razak, 05460 Alor Star, Kedah DarulAman, MALAYSIA Tel: +6 04-730 4777 Fax: +6 04-730 5777 email: admissions@aiu.edu.my website: www.aiu.edu.my