Executive MBA Program

INSTITUTE OF BUSINESS ADMINISTRATION

UNIVERSITY OF DHAKA Photo

Application for Admission

(Semester- Summer 2011)

Instructions
1. This application form comprises 3 (three) separate pages.
2. After filling in the form, put your signature on the 4 (four) designated places.
3. Include 2 (two) recent, color, Passport Size photos with the application.
4. Do not write anything in the shaded areas designated “For Office Use Only”.
5. Make a Pay Order / Bank Draft for Tk.1500, payable to “Executive MBA, IBA”.
6. Submit the filled-in form & the Pay Order /Bank Draft to the EMBA Program Office by Tuesday, April 26, 2011.
7. After submitting this form, collect your Admit Card from EMBA Program office at IBA on the assigned delivery
date.

Personal Data
Fill applicant name in BLOCK letters. If currently unemployed, provide only one contact address.

Name:                  

Last/Family First Middle

Mother’s Name:      

Father's Name:      

Date of Birth:    /    /     

dd mm yyyy

Nationality:       National ID No / Passport No:

Gender: Male Female

Currently Employed? Yes No

Address 1:      
(Home)
     

Address 2:      
(Work)
     

     

Telephone #                  

Work Home Cell phone

Email:      

Initials

Signature of Applicant Receipt No. Admit No. Page 1 of 4

Work Experience
Give details of all full-time employment, starting from the most recent and going back at least 3 (three) years.
Position Organization Major Responsibilities Dates
                       

                       

                       

                       

                       

                       

Total Duration of Full-time Employment:    Years    Months

Academic Qualifications
Please list all degrees earned, starting from the most recent.
Degree Institution Date Area / Major Class/CGPA
Awarded
                             

                             

                             

                             

                             

GMAT Information (if applicable)

Last Test Verbal Quantitative Total Test Date:

Scores:
Raw Score:        
   /    /     
dd mm yyyy
Percentile:
         

Signature of Applicant Page 2 of 4

Signature of Applicant
Achievements, Memberships & Activities

Please list all noteworthy achievements / distinctions / awards, professional / association memberships &
voluntary / community activities (in order of perceived importance).

Achievement/Membership/Activity Organization/Field Dates

                 

                 

                 

                 

                 

                 

                 

Declaration

“The information provided in this application form is true and correct. I accept that IBA reserves the right
to restrict my admission or cancel my registration at any time if any item of information given by me on
this form is found to be materially false or incorrect.”

Date: / /
Signature of Applicant dd mm yyyy

Application Fees Payment Information

Pay Order/Bank Draft #       Payable to “Executive MBA, IBA”

Bank:       Dated:    /    /     

dd mm yyyy

Name of Applicant (in BLOCK letters) Signature of Applicant

Executive MBA Program

Institute of Business Administration
University of Dhaka
(Semester- Summer2011)
Admit # Photo

Page 3 of 4
Receipt No Signature of IBA Official

Page 4 of 4