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Specimen Application

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SPECIMEN APPLICATION

STATE PHARMACEUTICALS MANUFACTURING


CORPORATION

FOR THE POST OF…………………………………………

1. Full Name of the Applicant : …………………………………………………………………………


2. Name with Initials : ………………………………………………………………………...
3. Permanent Address : …………………………………………………………………………
4. District : …………………………………………………………………………
5. Date of Birth : …………………………………………………………………………
6. Age as at Closing date of application : …………..... Years ……………..Months …………... Days
7. Sex : …………………………………………………………………………
8. Civil Status : …………………………………………………………………………
9. NIC No : …………………………………………………………………………
10. Contact No : …………………………………………………………………………
11. Educational Qualifications
G.C.E (O/L) – YEAR …………………….
SUBJECT GRADE SUBJECT GRADE

G.C.E (A/L) – YEAR ………………………


SUBJECT GRADE SUBJECT GRADE

12. Degree
i. Valid date of Degree : ……………………………………………………………..
ii. University / Institution : ……………………………………………………………..
iii. Degree / Subject : ……………………………………………………………...

13. Postgraduate Qualification


i. Valid date of Postgraduate Degree / Diploma : ……………………………………………….
ii. University / Institution : ……………………………………………………………
iii. Subject : ……………………………………………………………
14. Professional qualifications : ……………………………………………………………………………………
……………………………………………………………………………………….

15. Other qualifications : ………………………………………………………………………………………………...

16. Experience : …………………………………………………………………………………………………

17. Details of Non related referees : …………………………………………………………………………………………………

I hereby declare that the details given above are true and correct to the best of my knowledge and belief.

Date : ……………………………….. Signature : ………………………………

Recommendation of Head of Department :


I hereby certify that Mr / Mrs / Ms ………………………………………. is employed in this Ministry / Department
/ Corporation / Board as …………………………………………… His / Her work and conduct are satisfactory and
the particulars furnished by him /her are correct. If selected he / she / can / cannot released from his /
her present post.

………………………………………………….. ………………………………………………
HEAD OF DEPARTMENT DATE

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