IELTS Application Form
Please return to:
Centre
stamp /
/ Candidate's
photo / 2 Copy Passport
Size Colour Photo
(5cm X 4cm)
*Please write your name on the back of the photograph.
No glasses and cap
* Please attach photographs by clip.
1 Preferred Date of Test
16 / 11 / 2012
(day / month / year)
/ For Office Use Only
Scheme: JICE JDS Project Office in Bangladesh
Test Date 16/ 11 / 2012
(day / month / year)
Date of Payment _____/______/____ Receipt Number ______
(day / month / year)
ID checked / Absent Administrator's initials______
(circle as appropriate)

2 Family/Sur Name 3 Dr Mr Mrs Miss Ms

(circle as appropriate)

4 Given/First Name ______

5 Other name(s)

(These names must be the same as the names on your Passport)

6 Address for correspondence: JICE JDS Project Office in Bangladesh, L-261, The Pan Pacific Sonargaon Hotel, 107, Kazi Nazrul Islam Avenue, Dhaka-1215.

7 Mobile No______8 e-mail

9 Date of Birth _____/______/______10 Sex F / M

(day / month / year) (circle as appropriate)

11 ID Type: Passport Passport Number

(This passport must be brought to the test)

12 Country of Origin Bangladesh / 0 / 1 / 5 / 13 First Language Bengali / 0 / 1 / 4

For questions 14, please enter codes. Codes will be found in the Application Guidelines(page 21).

14 Occupation (Sector)/(Level) / 4
15 Why are you taking this test? / 1

16 Which country are you applying/intending to go to? Japan

17 Which IELTS Modules are you taking? / Academic

(Please turn over)

18 Which IELTS test are you taking?
Pen and Paper test
Are you taking the Writing on paper Yes No

19 What level of education have you completed? (circle as appropriate)

Secondary up to 16 years / Secondary 16-19 years / Degree or equivalent / Post-graduate

20 How many years have you been studying English? (circle as appropriate)

Less
than 1 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9
or more

21 Your results sent to

Name of Person/Department JICE JDS Project Office in Bangladesh

Name of College/University/Institution N/A

Address Room # L-261, The Pan Pacific Sonargaon Hotel, 107 Kazi Nazrul Islam Avenue, Dhaka-1215

IELTS entry requirement (Band, if known)

22 Do you have any special needs?

23 Declarations

I certify that the information on this form is complete and accurate to the best of my knowledge.

I agree to accept all rules and regulation of British Council.

Signature______Date _____/______/____

(day / month / year)