A government supported training program.

1. Name of the Training Center/ Association:
Address of the Training/Association Center:
Telephone Number:
Email:
Web Address:
SEIP Trainee Admission Form
SEID : 113002
Course Applied : Practical SEO
Basic Information
Name : Kazi Md. Rokunuzzaman
Gender : Male
National ID Number : 5213366789144
(Copy of NID to be attached)
BirthRegistrationCertificateNumber: No need.
(If NID is not available then birth registration certificate to be attached)
(YYYY/MM/DD) : 1978/01/09
Present Address : House# 46, Road# 10, Block# D, Sector# 12
Mirpur, Dhaka.
Permanent Address :Village- South Parulia, Post Office- South parulia,
Police Station- Hatibandha, District- Lalmonirhat.
Home District&Upazila : Lalmonirhat, Hatibandha.
Mobile No : 01629-097783, 01944-998766.
E-mail :( If available) : kazimd998766@yahoo.com
I. Personal Information
Religion : Islam Ethnic Group: Sunni
Education Level: Highest Class Completed: B.Sc (Hon’s) Year : 1999
Are You Currently Employed? : No
Family’s Monthly Income (BDT) : 10,000Tk
Are you physically challenged? Yes
(* if ‘Yes) □Seeing □Movement □Hearing □Speech others: ________
Photo
(3 Copies)

2. Family Information
Mother’s Name : Mrs. Nurjahan Begum
Mother’s Education Level : S.S.C
Father’s Name : Late Kazi Md. Shamsul Alam (Freedom Fighter)
Father’s Education : H.S.C
Father’s Annual Income :
Does your family own home? : Yes
Does your family own land? : No
Number of brothers and sisters: One Brother and Two Sisters.
IV. Declaration:
1) I certify that I correctly provide my information and qualifications in the student admission form.
2) I express my willingness to render my services to the related industrial sector after completion of the
training program.
Signature of Trainee Date : 23/08/2015