AHEAD Scholarship Application Form

Annex 1: Application Form
Reference No O
HUMAN RESOURCE DEVELOPMENT PLAN - AHEAD
Selected ffi
Scholarship for PhD degrees for University Academic Staff Reserved ce
U
Application Form Rejected
Part A
1. Personal Information
Family Name (Surname): First/Other names:
Rev./Dr./Mr./Ms: Gender: Nationality:

Date of Day Month Year
Age: N.I.C No:
Birth:
E-mail Address: Address to which correspondence should be sent:
Contact Office Residence Mobile Fax

Numbers:
2. Qualifications
2.1 ACADEMIC: (Give full details in chronological order)
Certificates,
Main field(s) or
(Office
Points
From To University/ Institute Diploma, Degree
Use)
Subject(s) of
Month/Year Month/Year (Name, Place) obtained with
study
Grade/ Class etc.
2.2 PROFESSIONAL: (Give full details in chronological order)

From To
Professional Body Professional Qualification
Month/Year Month/Year
3. Employment Record: Starting with your present post, list in reverse order of positions held
3.1 PRESENT EMPLOYMENT:
Period
(Month/Year) Title of your post Faculty Department University/Institute
From To
3.2 PREVIOUS EMPLOYMENT (if Other than University)
Period
(Month/Year) Title of your post Name and Address of the employer
From To
4. Research/Publications/Articles/Abstract/Chapters in Books/Papers in Refereed Journals/

Others (Please attach additional pages when space provided is not adequate)
Points
Year Description (For Office
Use)
5. Academic Distinctions during and after undergraduate studies (Prizes, Medals, Scholarships
excluding Mahapola)
Points
Use)
6. Extra Curricular Activities (organization of/ active contribution to, activities)

Points
Use)
7. Language Proficiency
For languages other than mother tongue, enter Tick (√) next to GCE
appropriate number from code (1,2,3 or 4) below your mother Speak Read O/L
to indicate level of your language knowledge tongue Grade
CODE: 1. Nil Sinhala
2. Limited Tamil
3. Satisfactory English
4. Excellent Other (Specify)
8. Score of Other English Professional Exams
IELTS TOFEL Other (Please Specify)
Part B
2
9. Degree to be Registered for
Please Tick (√) the type of PhD program
Split- Site PhD [ ] Full PhD in a overseas University [ ]
Field of Study: Research Field:
Are you Already Offered a Placement/Registered: Yes No

If yes, Please give the following details * Please attach a copy of the placement letter
Name and the address of the University/Institution: Faculty/Deparment:
If a Split site PhD program, the foreign

Institution/s where training will be carried out and
the planned time period for foreign training
Date of commencement - Intended date of completion -
10. Supervisors’ Details

Name Highest Qualification Contact Details
Institutional Affiliation
11. Brief Description of the Proposed Research

Research Description-Brief Description of the Proposed Research (not more than 150 words) Attach a
separate paper if required.
12. Budget
3
Fees and expenses: course fees, registration fee, living expenses, bench fee etc. (provide expenses under
separate headings)
Financially support by another Institution: Yes No
If yes, Please give the following details

Source……………………..……………………………………… Year :………………
Approved Budget (Rs.).…………
Declaration
I certify that all information in this application to be complete and correct to the best of my
knowledge
…………………………………… ……………………
Signature of the Applicant Date
4
Part C
13. Recommendations
I confirm that I have read the application. The field of research/Degree programme for which an
offer for placement has been received is relevant to the Department.
The application is recommended and the applicant can be released full time for the entire period of
the Degree programme applied for.
Official Stamp
………………………….………………………… ………………………..
Name and Signature of Head of Department Date
The Application by Mr./Mrs./Ms…………………………………………………………………. is

recommended for submission.
Official Stamp
………………………….………………………….. ………………………..
Name and Signature of the Dean Date
The Application by Mr./Mrs./Ms…………………………………………………………………. is

recommended for submission.
Official Stamp
………………………….………………………… ……………………..
Signature of the Vice Chancellor Date

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Annex 1: Application Form

Rev./Dr./Mr./Ms: Gender: Nationality:

Contact Office Residence Mobile Fax

2.2 PROFESSIONAL: (Give full details in chronological order)

4. Research/Publications/Articles/Abstract/Chapters in Books/Papers in Refereed Journals/

6. Extra Curricular Activities (organization of/ active contribution to, activities)

Are you Already Offered a Placement/Registered: Yes No

If a Split site PhD program, the foreign

Date of commencement - Intended date of completion -

10. Supervisors’ Details

11. Brief Description of the Proposed Research

Financially support by another Institution: Yes No

If yes, Please give the following details

The Application by Mr./Mrs./Ms…………………………………………………………………. is

The Application by Mr./Mrs./Ms…………………………………………………………………. is

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