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Touchstone Terrace Flat B1 House 29 Road 9 Block G Banani Dhaka-1213
Mobile: 01844046677 Email: info@jabianclub.org

APPLICATION FOR MEMBERSHIP
FORM : MR0163 (Price Tk. 1,000)
DATE:
D D - M M - Y Y Y Y
NAME OF THE APPLICANT:
MEMBERSHIP TYPE:
LIFE MEMBER DONOR MEMBER GENERAL MEMBER
BASIC INFORMATION
FATHER'S NAME:
MOTHER'S NAME:
NATURAL DATE OF BIRTH: OFFICIAL DATE OF BIRTH:
BLOOD GROUP: RELIGION:
GENDER:
MALE FEMALE
MARITAL STATUS:
MARRIED UNMARRIED DIVORCED
10 DIGIT SMART NID: 13 DIGIT NID:
TIN NO.: PASSPORT NO.:
CONTACT NO.: ALTERNATE CONTACT NO.:
EMAIL: OFFICIAL EMAIL:
EDUCATION (ACHIEVED DEGREE)
Bachelor from JU (Mandatory) Masters (JU/Elsewhere) M Phil (JU/Elsewhere) PhD (JU/Elsewhere) Post Doctoral Other Degrees
JU ADMISSION BATCH:
JU PASS-OUT BATCH:
JU DEPARTMENT:
JU DORMITORY/HALL: HALL ROOM NO:
ADDRESS
FAMILY RESIDENCE DOMICILE WORKPLACE RESIDENCE
NOMINEE
NAME:
RELATIONSHIP: PROFESSION:
NID/ BIRTH REGISTRATION/ PASSPORT NO.:

Photo
OCCUPATION/JOB/WORK/BUSINESS INFORMATION
ORGANIZATION: DESIGNATION
ADDRESS:
FAMILY MEMBERS INFORMATION
RELATION NAME MOBILE NUMBER DATE OF BIRTH OCCUPATION
SPOUSE
CHILD-1
BOY GIRL
CHILD-2
BOY GIRL
SECONDER
MEMBERSHIP DETAILS SIGNATURE
OTHER SOCIAL/POLITICAL/CLUB/STATE/GLOBAL AFFILIATION
NAME OF ORGANIZATION MEMBERSHIP TYPE & NUMBER
APPLICANT SIGNATURE & DECLARATION
I here by declare that the information provided above is true to the best of my knowledge. I understand that any false declaration will make my application liable to cancellation & may result in expulsion from the club even it I am selected as a member. I also agree to abide by all the rules, regulations and code of conducts of Jabian Club Limited.
ENCLOSED
  1. Academic Certificate from JU
  2. National Identification Number (NID)
  3. Nominee's Photo & NID
Signature of Applicant
PLEASE DO NOT WRITE BELOW THE LINE (For office use only)
MODE OF PAYMENT:
Bank Transfer Cheque
Cash DFS/MFS
PAYMENT DETAILS:
Membership ID:
RECOMMENDATIONS & APPROVAL
MEMBERSHIP COMMITTEE SECRETARY GENERAL PRESIDENT
DATE:
D D - M M - Y Y
DATE:
D D - M M - Y Y
DATE:
D D - M M - Y Y