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THE FUTURE LEADERS PROGRAMME (FLP) Season 4
REGISTRATION FORM
Thank you for choosing to participate in The Future Leaders Programme (FLP) in 2016. Please fill out all sections of this
form. When completed, please submit your application at [email protected]
Please note that your information will be verified, and your participation will be denied if the information provided is
incomplete or incorrect
Instruction: Please double click on the appropriate box and select "checked" to complete.
1. EDUCATIONAL ATTAINMENT
Name of your last degree:
(example: Bachelor in Social Science in
International Relations)
Please specify when you have
completed that degree:
January
April
July
September
Year:
2. PERSONAL DETAILS
First Name:
Title:
Mr.
Family Name:
Mrs.
Miss
Ms.
Other
Gender:
Male
Female
Address:
City/Town:
Post Code:
Country:
Date of Birth (dd/mm/year):
Nationality:
Telephone Home:
Telephone Mobile:
Email:
Skype:
Passport Number:
First Language:
3. EDUCATION (SINCE THE AGE OF 14)
Year
Started
Year
Completed
Name of Institute
Qualification Obtained
Grade & GPA
4. EMPLOYMENT HISTORY & WORK EXPERIENCE (IF ANY)
Year
Started
Year
Completed
Name of Company
Type of work carried out
5. ENGLISH LANGUAGE QUALIFICATION (IF ANY)
IELTS
Listening Score
Reading Score
Writing Score
Speaking Score
Overall Band Score
6.
COMPUTER SKILL:
7.
TRAINING (IF ANY):
TRAINING TITLE
Other Recognised English Test
Listening Score
Reading Score
Writing Score
Speaking Score
Overall Band Score
TOPIC
INSTITUTE/ORGANISATION &
LOCATION
8.
EXTRA CURRICULAR ACTIVITIES & ACIEVEMENTS (IF ANY):
9.
DECLARATION OF DISABILITY, LEARNING DIFFICULTY OR HEALTH PROBLEMS
DURATION & YEAR
Do you consider yourself to have a disability, specific learning difficulty, or specific health problem?
Yes
No
If yes please provide details:
10. CRIMINAL RECORD:
Have you got any criminal record in Bangladesh or abroad? Yes
No
If yes , please provide details:
11. HAVE YOU EVER APPLIED FOR A STUDENT VISA (WORLDWIDE):
11.1Please State Decision of that Application.
YES (GOTO SECTION 11.1)
NO (GO TO SECTION 12)
Have you ever been refused a visa? Yes
No
If yes please give reason of refusal below and attach the Visa Issuing Authority’s refusal letter?
12. HOW DID YOU HEAR ABOUT THE FUTURE LEADERS PROGRAMME (FLP) SEASON 3?
Channel i
Other TV channel
FLL website
Social media
University
Newspaper
Friend
Other, please specify _______________________________
13. REFEERENCES: 1 REFEREE TO BE FROM THE UNIVERSITY LAST ATTENDED
REFERENCE (1)
REFERENCE (2)
Name
Name
Designation
Designation
Organization
Organization
Address
Address
Mobile
Mobile
Relationship
Relationship
14. DECLARATION
I wish to be considered for participation in The Future Leaders Programme (FLP) in 2015.
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I declare the information supplied in this form is correct and complete.
I consent to all publicity containing my image and information related to the FLP.
I acknowledge that the provision of false or misleading information may result in the non-acceptance of this
application or immediate expulsion from the Programme.
I authorise the FLP Authority to verify any information provided by me.
I authorise the FLP Authority to obtain, where necessary, from any other educational institution evidence of my
academic record or to seek other corroborating evidence with respect to my application.
I understand that the FLP Authority may disclose the personal information I have given in this application to other
Authorities where required or requested.
I consent to receiving information about any knowledge/ skills & career progression opportunities.
I hereby declare that the particulars given herein are true, correct and complete to the best of my knowledge and belief,
and I am not making this application for the purpose of contravention of any Act, Rules, Regulations or any statute or
legislation or any Notifications, Directions issued by any governmental or statutory authority from time to time.
Name:
Signature:
Date:
(For online applicants, please leave it blank if you can not add e-signature,
forwarding this form to FLP authority automatically confirms your consent)