•,xld w.aksos.

úsYajúsoHd,h
(fuu whÿñ m;%h iñsmq¾K lsÍug m%:ufhka th fyd|skA lshjd n,kak)

YsIHdOdr whÿñ m;%h

SEU/ IS / 20 / /

w.fmd.i W.fm< ,shdmosxÑ wxlh úsYajúsoHd, ,shdmosxÑ wxlh

mSGh :- .................................................

(Note: You are requested to fill up this form in English letters)

YsIHdOdr i|yd n,mdk fldkafoais

01. ;u whÿïmf;ys we;=<;a lsishï m%ldYhla wi;H fyda idjoH nj Tmamq jqjfyd;a
fyda ;u whÿïmf;ys lsishï jeo.;a lreKla fy,s lsßug wiu;a jQ nj Tmamq
jqjfyd;a wNHka;r YsIHfhl= jYfhka Tyqf.a / wehf.a ,shdmosxÑh wj,x.= ùug
hg;a fõ.

02. YsIHdOdr fyda uyfmd< i|yd whÿï l< YsIHhl= fyda tjekakla ,nñka isák
YsIHhl=f.a mjqf,a wdodhu, újdyl ;;a;ajh, fiajd kshqla;s wdodhï jeks °,
iïnkaOfhka fjkila ù we;akï ta nj jydu úYajúoHd,fha f,aLldêldßjrhd
fj; ,sÅ;j oekqï osh hq;=h.

03. YsIHdOdr yd uyfmd< YsIH;aj i|yd uqo,a f.jkq ,nkafka úYajúoHd,fha

wOHhk lghq;= j, fhoS isák ld,h ;=, muKs. ;u wOHhk lghq;=
;djld,slj w;aysgjqj fyd;a fyda mdGud,dj ksuùug m%:u thska bj;a jqjfyd;a
ta ms<sn|j jydu f,aLldêldß fj; oekaúh hq;=h.

04. my; i|yka tla lreKla fyda Bg jvd jeä .Kkla ksid lsishï YsIHfhl=g
uqo,a f.ùu iïmQ¾Kfhkau k;r lsÍug fyda ;djld,slj w;aysgqùug yelsh.

(w) YsIHhd lsishï úNd.hla wiu;a ùu, tfia jqjfyd;a m%:u j¾I
mßCIKfhka W!k idud¾:hla ,nd fojk j¾Ih i|yd kshñ;
mdGud,djla yodrk lsishï YsIHfhl=g YsIHdOdr f.úh yel.

(wd) Wm l=,m;sjrhdg ms<s.; fkdyels lsishï fya;=jla ksid ,eî we;s m%:u
wjia:dfõ oS lsishï úNd.hlg fmkS isàug YsIHhd wiu;a ùu.

(we) YsIHhd ;u wOHdmk lghq;= Wkkaÿfjka lrf.k fkdhdu.

(wE) YsIHhd úkh úfrdaë f,i yeisÍu.

(b) Wm l=,m;s úiska ;SrKh lrkq ,nk fjk;a m%udKj;a fya;=jla.

1
05. YsIHdOdr ;djld,slj fyda iïmQ¾Kfhka w;aysg jQ úg tu uqo,a h,s f.ùu
iïnkaOfhka úYajúoHd, n,Odßka úiska wNsu;h mßos ;SrKh lrkq ,efí.

06. iqÿiqlï ,nk YsIHhkag wOHdmk j¾Ihlg jdßl 10 l Wmßuhlg hg;aj

f.ùï lrkq ,efí.

07. idudkHfhka uyfmd< YsIH;aj i|yd n,mdk fldkafoais YsIHdOdr i|yd o n,

meje;afõ.

08. uyfmd< YsIH;aj wdOdr ,nk lsisu YsIHfhl=g YsIHdOdr f.jkq fkd,efí.

09. fudku fya;=jla ksidj;a kej; YsIHdOdr fmdaruhla ksl=;a lrkq fkd,efí.

YsIHdOdr fmdaruh msrùu i|yd Wmfoia

1. ishˆu wdodhï ud¾. iy wid we;s ishˆu úia;r i|yka l< hq;=h. i|yka
lrkq ,nk wdodhï úia;r wod< ks<Odßkaf.ka yd foaYsh wdodhï
fomd¾;fïka;=fjka úuid n,kq we;. úfYaIfhkau whÿïmf;ys wxl 14 “w”
yd “wd” fldgqj, i|yka lrkq ,nk foudmsh jd¾Isl wdodhï úia;rfhys
wod, jegqma úia;r, úY%du iy;sl, urK iy;sl, úY%du jegqma úia;r, f.a
fodr bvlvï j,ska jHdmdßl wdodhï wdosh ms<sn| ,shlshú,s whÿïm;g
weñKsh hq;=h.

2. lsisu fldgqjla ysiaj fyda yryg bß we| fyda fkd;sìh hq;=h. i|yka lsÍug
lsisjla fkdue;skï ta nj i|yka l, hq;=h. wiïmQ¾K fyda kshñ; oskg
fkd,efnk fyda .%dufiajd ks<Odß yd m%dfoaYsh f,alï u.ska fkdtjk
whÿïm;a m%;sfCIam lrkq ,efí.

3. fuu whÿïm; ksis mßos iïmQ¾K lr wod, ,shlshú,s iu. 30.06.2022 jk

osk fyda toskg fmr ,efnk fia tùu i|yd m<df;a .%dufiajd ks<Odß ;ek
fj; Ndrosh hq;=h. .%dufiajd ks<Odß ;ek úiska 19 jeks fldgqfõ úia;r lr
we;s mßos m%dfoaYsh f,alï u.ska kshñ; oskg fmr bosßm;a lrkq we;.
YsIHdOdr whÿïm; ,shdmosxÑ ;emEf,ka túh hq;= fyhska ta i|yd re. 40.00
jákdlï we;s uqoaor we,jq úYajúoHd,fhys ,smskh ,shk ,o 6” x 9”
m%udKfha ,sms ljrhla iïmQ¾K lrk ,o YsIHdOdr b,aÆïm; iu.
.%dufiajd ks<Odß ;ekg Ndrosh hq;=hs. l=uk fya;=jla ksidj;a iy;sl l,
whÿïm; w;ska f.keú;a NdroSu fkdl< hq;qhs.

4. Tn fuu whÿïmf;ys igyka lr we;s f;dr;=re wi;H njg úYajúoHd,fha

n<Odßkag ta;a;= .shfyd;a Tng ks;Hdkql+,j oXqjï oSug fyda Tfí
wNHka;r YsIHNdjh wj,x.= lsÍug fyda isÿjk nj ;rfhaa jgyd.; hq;=hs.

5. YsIHdOdr uqo,a msßkeóu ms<sn| ;SrKh lsÍu iy th wvq lsÍu, jeä lsÍu,
m%;sfCIam lsÍu fyda fok ,o uqo,a k;r lsÍu wdosh ms<sn| ishˆu lreKq
;SrKh lrkqfha úYajúoHd,fhks. tu ksid YsIHdOdr ms<sn| lsisu b,a,Sula
úYajúoHd, m%;smdok fldñIka iNdjg fkdheúh hq;= w;r tjeks b,a,Sï
j,g ms,s;=re fkd,efnk nj o igyka lr.kak.

2
01. iïmQ¾K ku .................................................................................................................
............................................................................... ysñ/uy;d/fukúh.
iaÓr ,smskh .................................................................................................................
..................................................................................................................
.%du fiajd ks<Odß jiu :...................................................................................................
m%dfoaYsh f,alï fldÜGdYh :............................................................................................
osia;%slalh ................................................................................................................
Hand Phone No: ………………………….. NIC No……………………………….

02. Tfí iaÓr mosxÑ ia:dkfha isg (tkï ksjfia isg) •,xld w.aksos. úsYajúsoHd,hg
we;s ÿr m%udKh (b;d lsÜgq lsf,da ógrhg) ,shkak.
ie;mqï 1 = ls.ó. 1.6) ls.ó. ...............

03. mjqf,a úia;r

(w) jhi wjqreÿ 19 yd 19 g wvq mdi,a hk ifydaor ifydaoßhka / ifydaor
ysñjreka ms<sn| úia;r fuys i|yka lrkak. wjYH jQ úgl Wmamekak
iy;sl bosßm;a lsÍug iQodkñka isáh hq;=hs.

bf.kSu ,nk
31.12.2021
ku Wmka oskh mdif,a /
oskg jhi
wdh;kfha ku
(1)
(2)
(3)
(4)

(wd) lsishï úsYajúsoHd,hl fyda fi!kao¾h wOHdmk wdh;kfha fyda foaYsh

ffjoH úoHd wdh;kfha fyda fjk;a Wiia wOHdmk wdh;khl mdGud,d
yodrk ifydaor / ifydaoßhka Tng isà kï Tjqka ms,sn| my; i|yka
úia;r imhkak.

Wiia
wOHdmk
YsIHdOdr /
mdGud,dj yodrK uyfmd,
,shdmosxÑ wOHdmk
ku Wiia wOHdmk mdGud,dj YsIH;ajh
wxlh j¾Ih
wdh;kfha ku fyda fjk;a
YsIH;ajhka
,nk /
fkd,nk nj
(1)
(2)
(3)
(4)

3
 (we) by; (w) iy (wd) fldgiaj,g we;=,;a fkdjq hï ifydaor ifydaoßhka
Tng we;ao? isà kï Tjqka ms<sn| my; i|yka úia;r imhkak.

jhi /lshdjla lrkafka kï

/lshdjla lrk /
ku wdh;kfha ku / mdi,a
wjqreÿ udi mdi,a hk
hkafkakï mdif,a ku
(1)
(2)
(3)
(4)
(5)

04. Tfí mshd / uj / wújdyl ifydaorhl= / wújdyl ifydaoßhl= wdodhï nÿ

f.jkafka kï ta ms<sn| my; i|yka úia;r imhkak.

ku {d;s iïnkaOh wdodhï nÿ ,sms f.dkq wxlh

(1)
(2)
(3)
(4)

05. óg by;ska úYajúoHd,hl fyda fjk;a Wiia wOHdmk wdh;khl mdGud,djla

Tn yodrd we;s kï fyda Wmdêhla ämaf,daudjla fyda fjk;a iy;slhla Tn bka
,nd we;akï ta ms<sn| my; i|yka úia;r imhkak.

wdh;kfha ku : ..................................................................................................................

,nd.;a Khla we;akï tys úia;r

mdGud,dj yeoErE ld,h ,nd.;a
nexl=j oskh
uqo,

4
06. rcfhka fyda m<d;a md,k fyda fjk;a wdh;khlska fyda iñ;shlska YsIH;ajhla
fyda fjk;a wdOdr uqo,la Tn oekg ,nkafka kï ta ms<sn| úia;r yd ,efnk
uqo,a m%udKh :......................................................................................................................
................................................................................................................................................
07. hï /lshdjla lrk wújdyl ifydaorfhla fyda ifydaoßhla Tng we;akï
Tyqf.a / wehf.a wdodhï ms<sn| úia;r.

/lshdjla lrkafka
kshq;= /lshdj yd /lshdfjka ,efnk kï wdh;kfha ku
ku
ia:dkh wdodhï / mdi,a hkafka kï
mdif,a ku
(1)
(2)
(3)
(4)

08. mjqf,a /lshd lrk wújdyl ifydaor ifydaoßhkaaf.a jd¾Isl wdodhï tl;=j
remsh,a (wl=ßka) : ................................................................................................................

09. bvlvï j,ska ,efnk wdodhï :

bvu
jd¾Isl
whs;slref.a «d;s msysá jeú,af,a m%udKh
wdodhï
ku iïnkaOh ia:dkh iajNdjh foam, .ek
remsh,a
úia;r
(1)
(2)
(3)

5
10. ksjdi j,ska ,efnk wdodhu

l=,shg
noaog oS
;sfí
.Dy kï
whs;slref.a {d;s jßmkï jd¾Isl
uQ,sl ,smskh tfia
ku iïnkaOh wxlh wdodhu
wxlh ,nd .;a
whf.a
ku yd
,smskh

1. by; i|yka f.j,a / ksjdi msysá .%du fiajd ks<Odß fldÜGdifha wxlh : ...........
2. m%dfoaYsh f,alï fldÜGdYh : ...........................................................................................
3. m<d;a md,k wdh;kfha ku : ...........................................................................................

11. Tn /lshdjla lrkafka kï muKla fuu fldgi iïmQ¾K lrkak.

/lshdj lrk wdh;kfha / fomd¾;fïka;=fõ ku iy ,smskh : ................................
................................................................................................................................................
;k;=re : .................................... j¾;udk jegqm (ishˆ oSukd iys;j) : .....................
jegqma l%uh : ..................................................................... m;ajQ oskh :............................

b,a,d wiajQ njg fyda wOHdmk ksjdvq ,efnk njg wdh;kfhka /

fomd¾;fïka;=fjka ,nd.;a ,smshla weñKsh hq;=hs.

12. Tn újdy ù we;akï muKla fuu fldgi iïmQ¾K lrkak.

újdy jQ oskh : ......................................................

(újdy iy;slh weñKsh hq;=hs)
iajdñmq¾Ihdf.a / Nd¾hdjf.a ku : ..................................................................................
/lshdjla lrkafka kï /lshdj lrk wdh;kfha ku : ..............................................
ork ;k;=r : ...........................................
j¾;udk jegqm : ................................
(ishˆ oSukd we;=ˆj uilg ,efnk jegqm i|yka l< hq;=hs)

13. Tn • ,xldfõ mqrjeisfhlao keoao hk j. : ....................

6
14. foudmshka / Ndrlre ms<sn| úia;r (Ndrlrejka hgf;a hefmk whÿïlrejka óg
wu;rj 16 fldgqjo msrúh hq;=hs)

(w) mshd ms<sn| úia;r

1. iïmQ¾K ku : .................................................................................................................

2. cSj;aj isào keoao hk j. : .....................................................................

(ñh f.diakï urK iy;slh weñKsh hq;=hs)

3. cSj;aj isákafka kï jhi : wjqreÿ : ........... udi : ...........

4. mshdf.a /lshdj : ................................................

(ñhf.dia kï ñh hdug fmr fyda úY%du f.dia kï úY%du hdug fmr kshqla; jQ
/lshdj i|yka lrkak)

5. /lshdj lrk / /lshdj l< ia:dkfha ,smskh (wxl 4g wod,j) : ........................

6. /lshdfjka / úY%du jegqfmka ,efnk jd¾Isl wdodhu i|yka lrkak

re. ........................... (31.12.2021 jk oskg ,enQ jd¾Isl uqˆ wdodhu i|yka
l< hq;=h) (/lshdjla lrkafka kï ishˆ oSukd iys;j j¾Ihlg ,efnk jegqm
i|yka lr fiajd wdh;kfha m%Odkshdf.ka ,nd .;a iy;slhla fyda úY%du f.dia kï
ishˆ oSukd we;=ˆj j¾Ihlg ,efnk úY%du jegqm i|yka lr úY%du jegqma
wOHCIlf.ka fyda m%dfoaYsh f,alïf.ka fyda ,nd .;a iy;slhla weñKsh hq;=h)

7. f.a fodr bvlvï j,ska ,efnk jd¾Isl wdodhu : ................................

8. wksl=;a ishˆ ud¾. j,ska ,efnk jd¾Isl wdodhu :..............................

mshdf.a uqˆ jd¾Isl wdodhfï tl;=j : ..............................

(wd) uj ms<sn| úia;r

1. iïmQ¾K ku : .........................................................................................................

2. cSj;aj isào keoao hk j. : ........................

(ñh f.diakï urK iy;slh weñKsh hq;=hs)

3. cSj;aj isákafka kï jhi : wjqreÿ : .......... udi : ..........

4. ujf.a /lshdj : ...............................................

(ñhf.dia kï ñh hdug fmr fyda úY%du f.dia kï úY%du hdug fmr kshqla; jQ
/lshdj i|yka lrkak) (úY%du f.dia kï úY%du iy;sl weñKsh hq;=hs)

5. /lshdj lrk / /lshdj l< ia:dkfha ,smskh : ................................................

7
 (wxl 4g wod,j)
6. /lshdfjka / úY%du jegqfmka ,efnk jd¾Isl wdodhu i|yka lrkak.
re. ...............................
31.12.2021 oskg ,enQ jd¾Isl uqˆ wdodhu i|yka l< hq;=h) (/lshdjla lrkafka
kï ishˆ oSukd iys;j j¾Ihlg ,efnk jegqm i|yka lr fiajd wdh;kfha
m%Odkshdf.ka ,nd .;a iy;slhla fyda úY%du f.dia kï ishˆ oSukd we;=ˆj
j¾Ihlg ,efnk úY%du jegqm / fyda jd¾Isl iïmQ¾K jekaoUq wk;aore úY%du
jegqm fyda i|yka lr úY%du jegqma wOHCIlf.ka fyda m%dfoaYsh f,alïf.ka fyda
,nd .;a iy;slhla weñKsh hq;=h)

7. f.a fodr bvlvï j,ska ,efnk jd¾Isl wdodhu : ...........................................

8. wksl=;a ishˆ ud¾. j,ska ,efnk jd¾Isl wdodhu : ........................................

ujf.a uqˆ jd¾Isl wdodhfï tl;=j : ....................................

15. mshdf.a iy ujf.a uqˆ jd¾Isl wdodhïj, tl;=j (wl=frka) :

................................................................................................................................................
(14 w iy wd fldgqj, wdodhï tl;=j)

16. Ndrlrejka iïnkaO úia;r

foudmshka fkdue;s fyda fouõmsh Ndrldr;ajfhka fjka jQ meúos whÿïlrejka
fyda Ndrlrejka hgf;a isák whÿïlrejka úiska fuu fldgi msrúh hq;=hs.

1. Ndrlref.a ku : ......................................................................................................

2. Ndrlref.a jhi : .....................

3. iaÓr ,smskh : ...........................................................................................................

4. /lshdjla lrkafka kï ;k;=r : ..........................................................................

5. jd¾Isl jegqm : ...............................

(jegqma úia;r weñKsh hq;=hs)

6. f.a fodr bvlvï / úydria: foam, bvlvï j,ska ,efnk jd¾Isl

wdodhu : .....................................
(fï i|yd .%dufiajd ks<Odß / m%dfoaYsh f,alï úiska ksl=;a l< iy;slhla
weñKsh hq;=hs)

8
17. whÿïlref.a m%ldYh :

by; i|yka lreKq uf.a oekSfï yd úYajdifha yeáhg i;H yd ksjeros njo,
wdodhï nÿ fkdf.jk njo, fuhska iy;sl lrñ. ;jo hïlsis f;dr;=rla wi;H
nj úYajúoHd, n,Odßkag ta;a;= .shfyd;a fuu whÿïlrejkag imhd we;s
Wmfoia ud,dfõ 4 jk j.ka;sh hgf;a ug úreoaOj l%shdl, yels nj uu oksñ.

oskh : .............................. ..........................................

whÿïlref.a w;aik

18. .%du ks<Odß yd m%dfoaYsh f,alï hk ks<Odßkag Wmfoia

1. whÿïlref.a m%foaYfha ;;a;ajh wkqj f.a fodr bvlvï j,ska ,eìh yels
idudkH wdodhu;a whÿïm; msrùfï oS whÿïlre úiska 09 yd 10 jk
fldgiaj, i|yka lr we;s f.a fodr bvlvï iïnkaO wdodhu;a .ek
iqmßCIdldßj i,ld ne,Sh hq;=h. whÿïlref.a ifydaor ifydaorhska
ms<sn|j whÿïlre úiska i|yka lr we;s f;dr;=rej, i;H;djh;a
uõmsh jd¾Isl wdodhu ms<sn|j whÿïmf;a 14 (w) iy (wd) fldgqj,
i|yka lr we;s f;dr;=re ;yjqre lsÍu i|yd bosßm;a lr we;s ,shú,s
iu. mÍCId fldgd tajdfha i;H;djh;a Tyqf.a m%ldYlhka Tn iy;sl
l< hq;=h.

2. tfia iy;sl lrkq ,nk whÿïm; Tn jifï m%dfoaYsh f,alï fj;

bosßm;a l< hq;=h. lsisu wjia:djl l=uk fya;=jla ksidj;a whÿïlre
w;g ndr fkdosh hq;=h

3. m%dfoaYsh f,alï úiska .%dufiajd ks<Odß ;ekf.a w;aik iy;sl fldg 10

4. 31.06.2022 oskg fyda toskg fmr ,efnk fia fuu whÿïm; ,shdmosxÑ
;emEf,ka my; i|yka ,smskhg túh hq;= fõ. ta i|yd re. 40.00 l
jákdlulska hq;a uqoaor we,jQ úYajúoHd,fha ,smskh ,shk ,o (9” x 4”)
ljrhla whÿïlre úiska .%dufiajd ks<Odß;ek fj; Ndr fokq ,efí.

,smskh : Deputy Registrar

Staff & Students’ Welfare Division,
South Eastern University of Sri Lanka,
University Park,
Oluvil # 32360.

9
19. .%du ks<Odß;ekf.a ku : .........................................................................................

.%du ks<Odß wxlh yd jiu : .................................................................................

foudmshkaf.a / Ndrlref.a jd¾Isl wdodhu : ....................................

wxl 14, 15 iy 16 fldgqfõ oelafjk fouõmsh / Ndrlref.a jd¾Isl wdodhuo,

foam, ms<sn| úia;r yd ifydaorhska ms<sn|j úia;ro, whÿïlref.a m%ldYho
bosßm;a lr we;s ,shú,s iu. ii|d neÆ w;r tajd uf.a oekSfï yd úYajdifha
yeáhg ksjeros nj fuhska iy;sl lrñ.

oskh : .................................... ...................................................

(.%du ks<Odß;ekf.a w;aik)

ks, uqo%dj

m%dfoaYsh f,alïf.a ku : ........................................................................................

m%dfoaYsh f,alïf.a w;aik : ........................................................................................

m%dfoaYsh f,alïf.a ks, uqo%dj

fldÜGdYh : ......................................... ;eme,a ld¾hd,h : ............................................

oskh : ..............................

(wod, fkdjk jpk lmd yßkak)

Deputy Registrar,
Staff & Students Welfare Division,
South Eastern University of Sri Lanka,
University Park,
Oluvil # 32360.
0672255181

10