(READ instructions before completing this application)

Sri Lanka - Canada Scholarship Foundation - Application for a Scholarship

1. Name in full: ........ 2. Mailing address: ......... ...E-Mail (if any): ..... 3. Phone no (if any): .. Male/Female: Date of Birth (Date/Month/Yr): ....... 4. School & Address: ......... 5. G.C.E. (O/L) Subjects & Results (Indicate A/B/C/S/W): No: 1 2 3 4 5 Subject Result .Exam year: ... Exam Index No: ... No: 6 7 8 9 10 Subject Result

To be completed by School Principal: I certify the above GCE (O/L) results to be true and accurate. Name of School Principal: . Signature: .... Phone No: Date: .... 6. Details of family members and their gross monthly income (BEFORE any deductions) from all sources (including other scholarships, Samurdhi allowances, etc.). For brothers, sisters, etc., write the relationship in the Relationship column. Name Relationship Applicant Father Mother Occupation
Gross Monthly Income Place School Principals official stamp in this area

7. To be completed by Grama Officer: I certify that the above family details are true and accurate and the TOTAL monthly income of the family (BEFORE deductions) is Rs: .. (Total income to be hand-written by the Grama Officer). Name of Grama Officer: .. Address: . Signature: ... Phone No: Date: .. 8. How did you learn about these scholarships? If you wish to include any other relevant details, write them on the other side of this form. I certify that all of the above information is true and accurate. (If false information is provided, the scholarship will be
cancelled.) Place Grama Officers official stamp in this area

Signature of Applicant: ......

Date: ....

(READ instructions before completing this application)