SELF ASSESSMENT FORM - Asian University for Women

Office of AdmissionsAsian University for Women20/G. M.M. Ali Road,Chittagong - 4000 BangladeshTel: +880-31-2854980Fax: +880-31-2854988Email: admissions@auw.edu.bdWebsite: www.asian-university.orgFor the Office of Finance Use OnlyApplicant ID:Name:Country:Documents missing:Form complete? £ Yes £ NoSELF ASSESSMENT FORMFINANCIAL INFORMATIONAUW offers a wide range of financial assistance to qualified students from partial to full scholarships based upon an assessment ofthe student’s family’s financial situation. Filling out the remainder of this form and providing supporting documentation will allowthe applicant to be considered for financial aid.Incomplete forms will not be considered for financial aid. All information provided will be kept strictly confidentialApplicant NameCountryParents InformationParent’s NameLiving? (Yes or No)Parent Age:Parent Address:(If different from applicant’s address)Occupation:Position/Rank:Employer/Business Name:Employer/Business Address andTelephone Number:Education level:Any disabilities:Personal Information (Please Check The Box)FatherMotherNumber of family members in your family including you 1-4 5-7 more than 7Number of earning members in your family More than 2 2 1Number of dependent members in your family 1-3 4-6 more than 6List the relationship of each dependent member toyou (e.g., brother, sister, grandmother, etc)Your family resides in(House includes flats, apartments, duplexes, etc.)Own house Rented house Other (specify)Asset Information (Please Check The Box)Monthly income of your family in USD (Please Check The Box)Less than $100$100-1500$1,500- 3000$3000-4500$4500 -6000$6000 -7500$7500 -9000More than $ 90001

Sources of annual income for your family in USDSourcesSalaryBusinessInvestmentInterestAgricultureHouse propertyOther sourceTotalIncome in USD0How many family members, other than you,are attending college/University?1-2More than 2more than $10,000What is the total tuition your family is paying per yearfor the above family members$4,000 -10,000Less than $4,000Does your family own a car?YesNoIf yes, then what is the make & model?Which one do you think best describes yourfamily's economic status?How do you think people in your community wouldrate your family's economic statusIs your mother or any sister a graduate with aBachelor's degree.Who in your family has at least a Bachelor'sdegree?(List relationship to you. family means yourparents, grandparents, brothers, sisters, husband)Rich Upper Middle class Middle class PoorRich Upper Middle class Middle class PoorYesNoThe tuition, room and board at AUW is $12,000 per year. How muchper year your family will be able to pay towards your tuition, roomand board per year for the next four/five years?USD$0-2000$2000-4000$4000-6000$6000-8000$8000-10000$10000-120002

DocumentationSupporting Documents (Please attach all available forms of documentation, if applying for financial aid)Most recent Income tax certificate/acknowledgement receipt,issued by proper tax authority, with official stamps on it,AttachedUnavailable or N/Aindicating tax paid in the last tax yearCopy of Taxpayer Identification Number (TIN) or proper taxpayernumber/certificate issued by the tax authorityAttachedUnavailable or N/ALand tax form/rental receipt Attached Unavailable or N/AEmployer statement of most recent salary & otherbenefits/salary slipAttachedUnavailable or N/ABank Statements for last six months Attached Unavailable or N/ATrade License Attached Unavailable or N/ACommunity certification for farmers Attached Unavailable or N/AOther ______________________________________ Attached Unavailable or N/AIf any of the items above checked “Unavailable or N/A,” please provide a sworn statement of valid reason(s) signed by parent(s) in aseparate page. (Please write student’s name on all additional/supporting documents submitted with this form.Certification And Authorization (Please Read Carefully)We declare that the information provided in this application form and all of its attachments are true, correct, and complete. Theuniversity has our permission to verify the information reported by obtaining additional documentation as needed. We understandthat providing false information may result in revocation of an offer of enrollment or financial aid.XApplicant’s SignatureXMother’s SignatureXFather’s/Guardian’s signatureDateDateDate3