Southern University Bangladesh
GEC/Halishahar,Chittagong

New Student Application

General Information

Student Full Name  (Required)
Blood Group  (Required)
First Name   (Required)
Place of Birth  (Required)
Middle Name
Last name   (Required)
Picture File (Required)
Program
Semester interested in enrolling for
Gender Male Female
Home Phone   (Required)
Cell Phone
Email   (Required)
Religion
Race/Ethnic Origin
Birth Date   (Required) d/M/yyyy
Work Phone  (Required)
FAX
Address
City
State/Province
Zip/Postcode
Country
Destination
Agent
Country of Citizenship   (Required)


Guardian Contact Information

Guardian Name   (Required)
Relationship   (Required)
Phone   (Required)
Email   (Required)
Address   (Required)
City   (Required)
State/Province   (Required)
Zip/Postcode   (Required)
Country   (Required)


Permanent Contact Information

Address
City
State/Province
Zip/Postcode
Country
Phone


Emergency Contact Information

Contact Name   (Required)
Relationship   (Required)
Home Phone   (Required)
Work Phone   (Required)
Cell Phone   (Required)


Disability Information

Disability Yes No Not Selected
Description
Learning Difficulties Yes No Not Selected
Description


Parent's Information

Father's Name  (Required)
Mother's Name  (Required)
Address  (Required)
City  (Required)
Zip/Postal Code
Country  (Required)
Home Phone  (Required)
Work Phone  (Required)
FAX
Mobile Phone  (Required)
E Mail  (Required)


Educational Information

Institution Attended(1)  (Required)
Dates of Attendance(1)  (Required) From & To
Qualification with Group(1)  (Required)
GPA/Class(1)  (Required)
Institution Attended(2)  (Required)
Dates of Attendance(2)  (Required) From & To
Qualification with Group(2)  (Required)
GPA/Class(2)  (Required)
Institution Attended(3)  (Required)
Dates of Attendance(3)  (Required) From & To
Qualification with Group(3)  (Required)
GPA/Class(3)  (Required)
Institution Attended(4)  (Required)
Dates of Attendance(4)From & To
Qualification with Group(4)  (Required)
GPA/Class(4)  (Required)
Institution Attended(5)  (Required)
Dates of Attendance(5)  (Required) From & To
Qualification with Group(5)  (Required)
GPA/Class(5)  (Required)
Institution Attended(6)
Dates of Attendance(6)  (Required) From & To
Qualification with Group(6)  (Required)
GPA/Class(6)  (Required)


Work Experience

Employer’s Name & Address(1)  (Required)
Position & Title(1)  (Required)
Period Employed(1)  (Required) From & To
Employer’s Name & Address(2)  (Required)
Position & Title(2)  (Required)
Period Employed(2)  (Required) From & To
Employer’s Name & Address(3)  (Required)
Position & Title(3)
Period Employed(3)From & To
Employer’s Name & Address(4)
Position & Title(4)
Period Employed(4)From & To
Employer’s Name & Address(5)
Position & Title(5)
Period Employed(5)From & To



Tuition & Fees Payment Information

Tuition Rate
Payment Method
Payment Plan Full Payment
2 installments
4 installments
All tuition and fees will be billed according to this payment plan.


By submitting this form, I hereby declare that I have read, understood and accept the conditions of the University Catalog & status. I agree to abide by the University’s rules and regulations. I certify that the information provided in this application form is true. I understand that providing false information may result in immediate dismissal or discontinuation and forfeiture of financial payments and academic credits in Southern University. By signing also means, I authorize Southern University to use my still photograph and my audio video clip to development purpose.