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THE FUTURE LEADERS PROGRAMME (FLP) in BUSINESS & SCIENCE

2014 REGISTRATION FORM
(THIS IS NOT AN ENROLMENT FORM)
Thank you for choosing to participate in The Future Leaders Programme (FLP) in Business & Science
2014. Please fill out all sections of this form. When completed, please submit your application to
your relevant department or send by email to apply@thefutureleaders.co.uk
Please note that your information will be verified, and your participation will be denied
if the information provided is incomplete or incorrect

Instruction: Please double click on the appropriate box and select

"checked" to complete.
1. EDUCATIONAL ATTAINMENT
Name of your last degree:
Please specify when you have
completed that degree:

January

April

July

September

Year:

2. PERSONAL DETAILS
First Name:
Title Mr.
:
Address:

Family Name:
Mrs.

Miss

City/Town:

Ms.

Other

Gender:

Male

Post Code:

Female

Country:

Date of Birth (dd/mm/year):

Nationality:

Telephone Home:

Telephone Mobile:

Email:

Skype:

Passport Number:

First Language:

3. EDUCATION (SINCE THE AGE OF 14)

Year
Started

Year
Completed

Name of Institute

Qualification
Obtained

Grade

4. EMPLOYMENT HISTORY & WORK EXPERIENCE (IF ANY)

Year
Started

Year
Completed

Name of Company

Type of work carried out

5. ENGLISH LANGUAGE QUALIFICATION (IF ANY)

IELTS
Listening Score
Reading Score
Writing Score
Speaking Score
Overall Band
Score

Other Recognised English Test

Listening Score
Reading Score
Writing Score
Speaking Score
Overall Band Score

6. DECLARATION OF DISABILITY, LEARNING DIFFICULTY OR HEALTH PROBLEMS:

Do you consider yourself to have a disability, specific learning difficulty, or specific health
problem?
Yes
No
If yes please provide details:

7. CRIMINAL RECORD:
Have you got any criminal record in Bangladesh or abroad?

Yes

No

If yes , please provide details:

8. HAVE YOU EVER APPLIED FOR A STUDENT VISA (WORLDWIDE): YES (GOTO SECTION
8.1) NO (GO TO SECTION 9)
8.1Please State Decision of that Application.
Have you ever been refused a visa? Yes

No

If yes please give reason of refusal below and attach the Visa Issuing Authoritys refusal letter?

9. HOW DID YOU HEAR ABOUT THE FUTURE LEADERS PROGRAMME (FLP) IN BUSINESS &
SCIENCE 2014?
Channel i

Other TV channel

FLL website

Social media

University

Newspaper

Friend
_______________________________

Other, please specify

10.DECLARATION
I wish to be considered for participation in The Future Leaders Programme (FLP) in Business &
Science 2014.

I declare the information supplied in this form is correct and complete.

I consent to all publicity containing my image and information related to the FLP.
I acknowledge that the provision of false or misleading information may result in the nonacceptance of this application or immediate expulsion from the Programme.
I authorise the FLP Authority to verify any information provided by me.
I authorise the FLP Authority to obtain, where necessary, from any other educational
institution evidence of my academic record or to seek other corroborating evidence with
respect to my application.
I understand that the FLP Authority may disclose the personal information I have given in
this application to other Authorities where required or requested.

I hereby declare that the particulars given herein are true, correct and complete to the
best of my knowledge and belief, and I am not making this application for the purpose
of contravention of any Act, Rules, Regulations or any statute or legislation or any
Notifications, Directions issued by any governmental or statutory authority from time to
time.
Name:
Signature:
(For online applicants, please leave it blank, forwarding this
form to FLP automatically confirms the consent)

Date: