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 1

ffjoH úoHd mYapd;a Wmdê wdh;kh

fld<U úYaj úoHd,h'

POSTGRADUATE INSTITUTE OF MEDICINE

UNIVERSITY OF COLOMBO

……………………………………………… ;k;=r i|yd whÿïm;

APPLICATION FOR THE POST OF ………………………………. …………

01' ^w& uq,l=re iuÕ ku :

^uhd$ ñh$ fuh o hk j.&
(a) Name with Initials :
(Whether Mr/ Mrs/ Miss)

^wd& uq,l=re j,ska ye¢kafjk kï :

(b) Names denoted by Initials:

02' ^w& s h:
;eme,a ,ssmk
(a) Postal Address:

^wd& s h:
fm!oA.,sl ,ssmk
(b) Private Address:

^b& fiajd ia:dkh :

(c) Place of work:

03' ^w& Wmka oskh : ^wd& whÿïm;a Ndr.kakd wjidk oskg jhi:
^Wmamekak iy;slfha msgm;la wuqKd tjkak&
(a) Date of Birth: (b) Age as at the closing date of application
(Attach copy of Birth Certificate)
wjq : udi : Èk(
Year : Month : Dates:

04' újdyl $ wújdyl nj$Civil Status:

05' ÿrl:k wxlh : úoHq;a ;eme,a ,smk

s h(
Telephone No: E mail Address :

06' Y%s ,xldfõ mqrjeisfhla o @ tfia kï Wmam;a;sfhka o @ ,shdmosxÑ ùfuka o @

,shdmosxÑùfuka kï ,shdmosxÑ wxlh :
State Whether a citizen of Sri Lanka by Descent or Registration.
If by registration, give Registration No:

07' wh;a ckj¾.h # ^isxy, øúv bkaoh s dkq iïNjhla we;s mqo. a ,hka fyda uqia,sï o hk j.&
State Whether Sinhala, Tamil, Person of Indian Origin or Muslim

osia;%slalh :
District :
 2

08' wOHdmk iqÿiqlï w'fmd'i ^iy;slj, msgm;a wuqKkak&

Educational Qualifications (Attach copies of Certificates)

^w& w' fmd' i ^id'fm<&

(a) (G.C.E. O/L)

m<uqjr fojkjr f;jkjr

1st Sitting 2nd Sitting 3rd Sitting
j¾Ih : j¾Ih : j¾Ih :
Year : Year : Year :
iu;a jQ úIhhka fY%aKsh iu;a jQ úIhhka fY%aKsh iu;a jQ úIhhka fY%aKsh
Subjects Passed Grade Subjects Passed Grade Subjects Passed Grade

^wd& w' fmd' i ^W' fm<&

(b) (G.C.E. A/L)

m<uqjr fojkjr f;jkjr

1st Sitting 2nd Sitting 3rd Sitting
j¾Ih : j¾Ih : j¾Ih :
Year : Year : Year :
iu;a jQ úIhhka fY%aKsh iu;a jQ úIhhka fY%aKsh iu;a jQ úIhhka fY%aKsh
Subjects Passed Grade Subjects Passed Grade Subjects Passed Grade

09' WiiA wOHdmkh ^iy;slj, msgm;a wuqKkak&

Higher Education (Attach copies of Certificates)

úYajúoHd,h/ WiiA wOHdmk yodrd we;s Wmdêh/mdGud,dj ld,iSudj mka;sh yd wjidk

wdh;kh Course/Degree followed Duration fY%aKsh úNd.fha
University/Name of Higher Class and oskh
Education Institute Grade Date of final
examination
 3

10' jD;a;Sh iqÿiqlï ^tjeks iqÿiqlï ,nd.;a oskhka wdosh olajkak& ^iy;slj, msgm;a wuqKkak&
Professional Qualification (Detail with the Date of obtaining such Qualification)
Attach copies of Certificates.
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................

11' isxy, $ bx.S%is úIhhkaf.ka iu;aj we;s by<u úNd.h

Highest Examination passed in Sinhala /English

^1& isxy, $ Sinhala

^2& bx.S%is $ English

12' whÿï lrkq ,nk ;k;=rg m<mqreÿ ld, iSudjka i|yka l< hq;= kï tu ld, iSudj
^iy;slj, msgm;a wuqKkak&

Where a period of experience is a requirement for the post applied state period of such
Experiences (Attach copies of Certificates)
…………………………………………………………………………………………………………..
………......................................................................................................................................................
………......................................................................................................................................................

13' oekg lrk /lshdj ^wod, jkafka kï muKs)

Present Occupation (If applicable)

;k;=r $ Post:

Bg m;a jq oskh $ Date of

appointment :
oekg lrk ;k;=frys ;yjqre lr
weoao hk j. : Whether confirmed
in the present post :
fiajd ia:dkh $ Place of work :
jegqma mrsudKh $ Salary Scale :
oekg jegqm $ Present Salary :
uQ,l
s $ Basic :
oSukd $ Allowance :

14 l,ska oerE ;k;=re we;skï ta ms<n s o úia;r oskhka o iys;j

Previous appointments including those under training if any with dates :

fomd¾;fïka;=j$ ;k;=r jegqma mrsudKh isg - olajd

wdh;kh Post Salary Scale From - To
Department/Institution
 4

15' fjk;a f;dr;=re

Any other Particulars
………………………………………………………………………………………………………….…………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………..
fuu b,a¨ïm;%fhys ud úiska i`oyka lr we;s úia;r i;H jq o ksjeros jq o tajd nj fuhska iy;sl lrñ. fuu
úia;r wi;H fyda jeros nj ud f;dard.ekSug fmr fidhd.kq ,enqj fyd;a udf.a whÿïm; m%;slafIam lrkq ,nk
nj o f;dard.ekSfuka miqj úia;r wi;H fyda jeros nj fidhd.kq ,enqj fyd;a lsisu jkaoh s la fkdue;sj ud
fiajfhka my lrkq ,nk nj o uu oksñ.

I certify that all Particulars stated by me in this application are true and accurate. I am aware that if these
particulars are found to be false or inaccurate prior to my selection, my application will be rejected and that
if particulars are found to be false or inaccurate after to selection, I will be dismissed from service without
compensation.

oskh ……………………….. ……………………………….

Date whÿïlref.a w;aik
Signature of applicant

igyk ( rdcH ixia:d fyda jHjia:dms; uKav, Wiia wOHdmk wdh;khkays fiajfha kshq;= whoquslrejka ;u
whoqusm;a wdh;k m%Odkshd u.ska tjsh hq;=h"

Note : Applicants in service of Government, Corporation or Statutory Boards, Higher Education

Institutions should forward their application through the Head of Institution concerned.

bosrsm;a lrus : Tyq $weh fuu ;k;=r i|yd f;dard .kq ,enqjfyd;a fuu jsYajjsoHd,fha wdh;kfha
fiajfhka uqod yersh yelsh$ fkdyelsh

Forwarded : He/She could be/could not be released from this University/Institution if selected for
an appointment.

……………………………………………………….
wOHlaI $f,aLldOsldrS $f,alus f.a w;aik yd ks, uqo%dj
Signature of the Director/Registrar/Secretary &
Official rubber stamp

oskh :
Date :

• wod, fkdjk oE lmd yrskk a

• Delete whichever is inapplicable