Bangladesh Agricultural University

Mymensingh
ADMISSION FORM
for
the Undergraduate Admission (Level-1, Semester-1)
Academic Year : 2022-2023 Roll Number
66563
Application Type
1. Full Name : MST. MARIYA KHAN ACHAL
2. Father's Name : MD. ASHRAF ALI KHAN
3. a) Father's Occupation : Private Job b) Annual income of Father: 216000
4. Mother's Name : MST. MAHFUZA KHANOM
5. a) Mother's Occupation : House Wife b) Annual income of Mother: 0
6. (a) Permanent Address : House#211/231, Malatinagar Shantibag Area, Word#11, Bogura Sadar-5800, Bogura
(b) Present Address : B.Sc in Agriculture (Honors), BAU, Mymensingh
(c) Mobile (Student) : 01734754061 Email (Student): mkachal2020@gmail.com
(d) Mobile (Father) : 01712567306 Email (Father): marufruet25@gmail.com
7. Date of birth : 26-08-2004 8. Place of Birth : Bogura, Bangladesh
9. Sex : Female 10. Religion : Islam
11. Nationality : Bangladeshi
12. Academic qualifications:

Name of GPA
Passing Year Name of the Board Name of the School and College Exam Roll
Exam. With 4 Subject Without 4thSubject
th

Bogra govt. girls' high school,

SSC 2020 RAJSHAHI 160983 5.00 5.00
Bogura
Govt Azizul Haque College ,
HSC 2022 RAJSHAHI 125616 5.00 5.00
Bogura
I do hereby declare that the facts and information given in this form are true to the best of my knowledge. My application/
selection/ admission shall automatically be cancelled if any of the given facts or information is proved false. I further pledge to
abide by the rules and regulations in connection with students’ discipline that are currently in force and those that may be laid
down in future.

Date: ........................... Candidate's Full Name: ...................................................................

To be filled in by the office
The selected candidate could be admitted to the Recommended for admission as a resident/non-resident

Faculty of ..................................................................... student in ............................................................... Hall.

Dean Proctor
Admitted as a resident/non-resident student in Admitted to the Faculty of ................................................

............................................................... Hall.

Registrar
Provost

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 বাংলােদশ িষ িবিবালয়
ম য় ম ন িসং হ

রিজেশন ফরম
িশাবষ ঃ ২০২২-২০২৩
Roll Number: 66563

(আেবদনকারীেক ফরম ডাউনেলােডর পর হে বাংলায় রণ করেত হেব)

অষেদর নাম

১. (ক) নাম (বাংলায়) : ....................................................................................................................................

(খ) নাম (ইংেরজীেত) : MST. MARIYA KHAN ACHAL
২. িপতার নাম : ....................................................................................................................................
৩. মাতার নাম : ....................................................................................................................................
৪. ায়ী কানা : ....................................................................................................................................
৫. বতমান কানা : ....................................................................................................................................
মাবাইল : 01734754061 ই-মইল: mkachal2020@gmail.com
৬. জ তািরখ : 26-08-2004 ৭. াড প: A(+ve)
৮. নাগিরক : বাংলােদশী ৯. ধম: ...........................................
১০. িশাগত যাতা :
া িজিপএ
পরীার নাম রাল নং িশা বাড  িশা িতােনর নাম পােশর বছর
(৪থ  িবষয় বােদ)
Bogra govt. girls' high
SSC 160983 RAJSHAHI 2020 5.00
school, Bogura
Govt Azizul Haque College
HSC 125616 RAJSHAHI 2022 5.00
, Bogura

১১. িবিবালেয় ভিতর কাটাগির : Merit

হেলর নাম (হল িনধ ারেণর পর িলখেত হেব):
১২.
.....................................................................................................
আিম অিকার করিছ য, এ ফরেম আমার দয়া সকল ত িনল এবং দানত কান ত িমা মািনত হেল আমার
ভিত সরাসির বািতল হেয় যােব, যােত আমার কান আপি থাকেব না।

_________________
তািরখ: ...............................
আেবদনকারীর ার

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 Bangladesh Agricultural University
Mymensingh

Level-1, Semester-1 of the Undergraduate Studies

Academic Year : 2022-2023 Roll Number

66563
MEDICAL CHECK-UP FORM Application Type

To be filled in by the Candidate

1. Full Name : MST. MARIYA KHAN ACHAL

2. Father's Name : MD. ASHRAF ALI KHAN
3. Mother's Name : MST. MAHFUZA KHANOM
4. Date of birth : 26-08-2004

Results of Medical check-up (to be filled in by the medical board)

Height: .......................................................... Teeth: .................................................................

Weight: ......................................................... Nose: ..................................................................
Chest size: .................................................... Throat: ...............................................................
Blood pressure: ............................................. Skin diseases: .....................................................
Blood group: A(+ve) Veneral disease: ................................................
Any mark(s) of identification: Hernia: ...............................................................
.......................................................................
Heart: ............................................................ Hydrocele: .........................................................
Lungs: ........................................................... Past history of diseases: .....................................
............................................................................
Eye: General health: ...................................................
............................................................................
a. Vision: Right .............................. Mental health: ....................................................
Left ................................ ............................................................................
b. Refraction: Right .............................. Verbal problems: ...............................................
Left ................................ ............................................................................
c. Other symptoms: Right ..............................
Left ................................

Comments: ............................................................ Comments: ...............................................................

Medical Officer Chief Medical Officer

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