Saubhagya Students’ Scholarship Scheme
Faculty of Medicine & Allied Sciences – Rajarata University of Sri Lanka
Application Form
A. Personal Details
1. Name in full:
2. Batch:
3. Registration Number:
4. Gender*: □ Male □ Female
5. Date of Birth:
6. Current age:
7. Religion:
8. Ethnicity:
9. National ID Number:
10. Permanent Address:
11. District where home is situated:
12. Current Accommodation*:
□ Home □ With relatives □ Hostel □ Private boarding place
□ Other (Please specify: ……………………………………………………………………………………………………………….. )
13. Do you wish to have direct contact with your donor? □ Yes □ No
If yes, the method of contact*:
□ Phone. Phone number: ......
□ Email. Email address: ......
□ Letter. Postal address: ......
□ Other. ......
* Mark √ in appropriate cage.
B. Details of your Family
Parents
Father / MotherName
Living or deceased?
Occupation
Monthly income/Pension
(Please attach valid documents to prove your family’s monthly income; i.e. GS certificate, Samurdhi receipt, Pay slip)
Details of your Brothers & Sisters
Name / Gender / Age / Married/ Unmarried? / Employed/Studying? (State the occupation if employed) / Place of Employment/StudyingC. Details of your Financial Status
1. Please give an account of your own monthly expenditure (boarding fees, food, study material, traveling etc.)
2. Do you currently receive any financial assistance?* □ Yes □ No
If yes, give details.
3. Please elaborate, giving reasons, why you think you are suitable to receive financial assistance under this scheme.
Please give true and correct details. Your information will be treated highly confidential. (Please attach valid documents to support your statements wherever possible).
I hereby state that the above given particulars and the attached documents are true and correct to the best of my knowledge.
I understand that if the above particulars are found to be false that the scholarship would be withdrawn and I would be made liable to pay back all monies received under this scheme.
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Signature Date
1