ACTUARIAL SOCIETY OF BANGLADESH

(Under Certification of Registration of Societies Act XXI of 1860 No. S-6732 (977) 07)
Rahamania International Complex,
Room # 16, 4th Floor,
28/1/C, Toyenbee Circular Road,
Motijheel C/A, Dhaka – 1000, Bangladesh.
E-mail: info@actuariesbd.org, Web-Site: www.actuariesbd.org

Membership No. :……./……./……. Affix

Your
Photograph
here

N.B: Before completing this form the applicant should study the Instructions and
Information given below. The completed form is lodged with the Society to the above
mentioned address only.

NOTES FOR APPLICANTS - Please Read Carefully

 Applicants are strongly recommended to discuss the implications of entering the

actuarial profession with an Actuary or a Founder Member of the Society
before submitting this application.
 Admission as a Student of the Actuarial Society of Bangladesh will normally be
granted to an applicant who meets the minimum entry standards prescribed in the
Student Handbook, copy of which is available from the Society or can be viewed
on the website, www.actuariesbd.org

This form must be completed in full. Please fill in your particular below in BLOCK
LETTERS and use black ink when filling in this form.

Page # 01
Part 1 – Applicants Details

Name:

Title: Mr. / Mrs. / Ms / Dr / If other please specify…………………………………

First Name: …………………………………………………………………………

Middle Name: ………………………………………………………………………

Last Name: …………………………………………………………………………

Nick Name: ………………………………………………………………………...

Father’s Name / Husband’s Name: ………………………………………………...

Mother’s Name: ……………………………………………………………………

Date of Birth: …………………………………………………………………………….

Blood Group: …………………………………………………………………………….

Nationality: ………………………………………………………………………………

Passport No. (Optional) : ……………………………………………………………….

Residential Details

Address: …………………………………………………………………………….

.....................................................................................................................

.....................................................................................................................

Tel. No. (Home): ……………………………………………………………………

Mobile No. : ………………………………………………………………………...

E-mail: ……………………………………………………………………………..
Failure to provide the correct correspondence address, telephone/mobile number and e-mail address,
in clear handwriting, will result in the applicant not receiving information about their application
form and forthcoming examinations.

Page # 02
Employer’s Details, if employed.

Name of Company: ……………………………………………………………….

Designation:……………………………………………………………………….

Address: …………………………………………………………………………….

.....................................................................................................................

Tel. No. (Office): ………………………………………………………………..

Fax No. : …………………………………………………………………………..

Mobile No. : ………………………………………………………………………..

E-mail: …………………………………………………………………………….

The office address will normally be published in the Actuarial Directory.

Study Details, if student.

Name of College/University: ……………………………………………………….

Address: …………………………………………………………………………….

.....................................................................................................................

.....................................................................................................................

Status: B.Sc / M.Sc / BBA / MBA / If other please specify………………………..

Roll: ……………………………… Reg. No. : ……………………………..

Subject: ……………………………………………………………………………..

Year: ………………………………………………………………………………..

Please indicate which address you would like all correspondence sent to: Office / Home

PLEASE NOTE: Members should notify the Secretary of any changes in personal details.

Page # 03
Part 2 – Actuarial Study Details (If any)

1. Actuarial Body/Bodies of which you are a member:

> Society of Actuaries (USA): Fellow / Associate / Student

> Institute of Actuaries (England): Fellow / Associate / Student
> Faculty of Actuaries (Scotland): Fellow / Associate / Student
> Institute of Actuaries of Australia: Fellow / Associate / Student
> Canadian Institute of Actuaries: Fellow / Associate / Student
> Actuarial Society of India (ASI): Fellow/ Associate/ Student
> Others (please specify): ………………………………………………………

(Note: Certified true copy of qualifications of the above bodies should be attached)

2. If you have passed and/or exempted from any part or subject,

please specify:-

Name of Actuarial Body: ………………………………………………………

Examination(s) passed/exempted: …………………………………………….
Date of the most recent examination: …………………………………………

Part 3 – Professional Qualifications

Professional association: ………………………………………………………....

Qualification: ……………………………………………………….....................
Year of Graduation: ………………………………………………………...........

Professional association: ………………………………………………………....

Qualification: ……………………………………………………….....................
Year of Graduation: ………………………………………………………...........

Professional association: ………………………………………………………....

Qualification: ……………………………………………………….....................
Year of Graduation: ………………………………………………………...........

Page # 04
Part 4 – Education and Qualification Details
Please give details of School, College and University and Professional achievements
attained with dates starting with S.S.C / O’levels

No. Title of Board/ Subjects Passed Result Passing

Examination University Year
01

02

03

04

05

06

07

NB: 1. Please enclose attested true copies of educational certificates and mark sheets for
all the examinations passed.
2. Attestation should be done by class one officer in government organization or
Professionals like C.A, Gazette Officer, Notary, Actuary or any Founder
Member of Actuarial Society of Bangladesh.

Part 5 – Class of Membership

Class of Membership sought:
 Fellow
 Associate
 Student
 Honorary :- () Fellow () Associate
() Observer () Member
Page # 05
Part 6 – Mode of Payments

You must indicate any sign for mode of payment: Cash / Cheque or DD

Amount (In Word): …………………………………………… ……………………

Figure: ………………………………………………………………………………

If Cheque or DD:
Cheque or DD No. : ……………………………………….Dated: ……………………..
Drawn on: ………………………………… Branch: …………………………………….
Bank: ………………………………………………………………………………………

Part 7 – Referees’ Declaration

All applicants are required to have their application form signed by two referees. A
referee should normally be Actuary / Founder Member of the Society / Department
Chairman / University Professor, or other professionally qualified person, who is
known to the applicant personally. Members of applicant’s own family cannot be
accepted as referees.

1st referee

The applicant is known to me for at least two years and, to the best of my knowledge and
belief, consider him/her to be a fit and proper person to be a Student of Actuarial Society
of Bangladesh.

Signature: …………………… Date: ………………… Occupation: ……………………

Name (BLOCK LETTERS): ……………………………………………………………….
Address: ……………………………………………………………………………………
……………………………………………………………………………………

2nd referee

The applicant is known to me for at least two years and, to the best of my knowledge and
belief, consider him/her to be a fit and proper person to be a Student of Actuarial Society
of Bangladesh.

Signature: …………………… Date: ………………… Occupation: ……………………

Name (BLOCK LETTERS): ……………………………………………………………….
Address: ……………………………………………………………………………………
……………………………………………………………………………………

Page # 06
Part 8 – Declaration to be signed by Applicant

I apply for admission as a Student Member of Actuarial Society of Bangladesh. If my

application is approved I agree to conform to the Rules and Professional Conduct
Standards as they currently exist or as they may in future be adopted, amended or
enlarged, and I will promote the objectives of the Society to the best of my ability. I
understand that to withdraw from membership I must inform the Society by paying or
giving back any arrears, delivery of books, papers or other property of the Society. I
further declare that I have not applied earlier to the Society for admission as a member.

Note: In case the applicant earlier for admission as a member, the details of same
should be furnished including whether such admission was granted or denied.

Signature………………………………….. Date…………………………………
Place………………………………...
Name (BLOCK LETTERS)………………………………………………………………..

Before signing this declaration you are strongly advised to read the Memorandum of Association and Rules
of the Society, which is available on our Web-site, www.actuariesbd.org.

Part 9 – Checklist

You must complete all parts of this section

Please complete and assigns the following.

I have: enclosed certified copies of all education certificates. (Page # 05)

provided an appropriate method of payment of the entrance fee and

subscription fee. (Page # 06)

provided details of two suitable referees. (Page # 06)

Signed and dated the applicant’s declaration. (Page # 07)

Signed:

Date:

Page # 07
 FOR OFFICE USE ONLY

Rept. No.

Date:

Amount:

Initial:

Page # 08