KYAMC

KYA-18 , Serial No:-.........

Khwaja Yunus Ali Medical College

Enayetpur, P.S:- Enayetpur, Chauhali, Sirajgonj-6751.
Tel: + 8802588834371-9, fax: +880 2588834431
(Founder: DR.M.M. AMJAD HUSSAIN)

Application Form For
Medical College Admission

Course Type:

Session: 2021-2022

General Freedom Fighter
Fill all the information that are required to go next step

Freedom Fighter :

Name of the freedom fighter *

Relation *

Personal Information :

Full Name *

নাম ( বাংলা ) *

Gender *
Male Female

Date of Birth *

Nationality *

Passport No.(Foreigners Only)

Mobile No *

Telephone No *

Email *

Directorate General of Health Services (DGHS) :

Roll No *

Test Score *

Merit Score *

Merit Position *

Collage Code *

Serial Number *

Family Information :

Father's Name * Is Guardian :

Father's Occupation *

Father's Designation

Organization

Contact No *

Email Address

Mother's Name * Is Guardian :

Mother's Occupation *

Mother's Designation

Organization

Contact No

Email Address

Guardian Name *

Guardian Relation *

Guardian Mobile *

Annual Income *

Guardian Address *

Address :

Present/ Mailing Address *

Both Same

Permanent Address *

Name of Guardian :

If other than parents

Telephone No.

Occupation

Relationship

Postal address

Result of Previous Examination :

Examination	Session *	Passing Year *	Grade *	Total GPA *

Name of address of two referees resident in your country who could testify to your character, academic background and capacity of further studies.
(Preferable from head of schools / college)

Reference 01 *

Reference 02

Photo & Signature Upload :

Applicant Passport Size Image: *

Parent/Guardian Signature: *

Applicant Signature: *

Admit Card / A Level Exam. Certificate: *

* Admit Card or Roll No Slip of HSC/ A Level Examination Certificate

Admission Test Admit Card : *

Admission Test Result: *

Payment Infomation :

Nagad Number: * (01915-477938)

Transaction No: *