Title**   Mr.   Ms.   Mrs.   Rev.   Other.

Name in full**

Initials**

Surname/Last name**

NIC/Passport No**	Date of Birth**	Gender**   Male   Female   Other

Residential Address (Address of permanent residence of the applicant)

Telephone No

Contact Address (Address to which the correspondence to be sent)

Mobile No

Contact email Address

Examination Year	Stream of Study	Index No	District	Z score
			Ampara   Anuradhapura   Badulla   Batticaloa   Colombo   Galle   Gampaha   Hambantota   Jaffna   Kalutara   Kandy   Kegalle   Killinochchi   Kurunegala   Mannar   Matale   Matara   Monaragala   Mullaitivu   Nuwara Eliaya   Polonnaruwa   Puttalam   Ratnapura   Trincomalee   Vavuniya

Subject	Result
	A   B   C   S   D   F   W
	A   B   C   S   D   F   W
	A   B   C   S   D   F   W
	A   B   C   S   D   F   W

Examination Year	Index No	Grade obtained for Mathematics
		A   B   C   S   D   F   W

Other Academic Qualifications
(Applicants who expect to seek admission from alternative qualifications other than A/L shall indicate details of such alternative qualifications for consideration)

Please note that candidates who do not have 3 passes in GCE (A/L) or equivalent and seek admission through alternative qualifications should pass
the Aptitude Test conducted by the University.

	Qualification(e.g. Diploma)	Subjects covered	Institution	Duration	Study Time Full Time/Part Time
+

Employment Status**  Employed  Not Employed  Self Employed

I certify that above information submitted by me are true and correct to the best of my knowledge.