Rajarata University of Sri Lanka, Mihintale

Application for New Student Enrolment

Academic Year 2 0 2 2 /2023
Note: Use English block capital letters to fill this application.

01 Registration No :- …………………………………………………………………….

02. National Identity Card or Passport No :- …………………………………………………

03. Index Number of the G.C.E. (A/L) Examination 2022 :- ………………………………………………………………

04. Selected Course of Study :- …......................…………………………………………………………………………………………

05. I. Name with Initials :- (Rev./Mr./Ms./ Other)…………………….…………………………………………………….

II. Full Name :- ……………………………..………................………………………………………………………….

……………………………..………................………………………………………………………….

……………………………..………………...............………………….……………………………….

06 Contact Details

I. Telephone No. :- ………..……..................... E-mail:……...............….…………………………………………

II. Permanent Address :- …………………………………………………………........................................................

…………………………………………………………........................................................

…………………………………………………………........................................................

III. Contact Address .……………………….………………………………………………………….............................

(If there is a

.……………………….………………………………………………………….............................
difference from
permanent address) .……………………….………………………………………………………….............................

07. Grama Niladhari Division:- ………………………..................... District:- ………………………………………………………………..

08. Race:…………………………………………………………………………… Religion:………………………………………………………………..

09 Gender:………………………………………………………………………. Civil Status:……………………………………………………………

10. Citizenship:…………………………………………………………………. (By Descent/ By Registration)

STUDENT ENROLMENT FORMS SECTION - I Page 1 of 4 Pages - (24)

11. Full Name of Father/Mother/Guardian:…………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………..

Occupation:………………………………………………………………………………………………………………………………………………………

Address of the place of work:…………………………………………………………………………..................................................

………………………………………………………………………………………………………………………………………………………………………….

Telephone Number:...…………………………………………………………

12. Name and the Telephone Number of the person to be informed in case of an Emergency

Name:……………………………………………………………………………………………………………………………………………………………….

Telephone:.............................................................................

13. Declaration of the Student/Applicant

1. I, ……………………………………………………………………………………………………………
…………………….(Name of Student) have carefully read and fully understood the law prohibiting
ragging referred in the Prohibition of ragging and other forms of Violence in Educational
Institutions Act, 20 of 1998.

2. I hereby undertake that;

2.1 I will not indulge in any behavior or act that may come under the definition of
ragging.

2.2 I will not participate in or abet or propagate ragging in any form

2.3 I will not hurt anyone physically or psychologically or cause any other harm.

3. I hereby agree that if am found guilty of any form of ragging, I may be punished as per the law
enforced any by-laws of the University.

4. I do hereby affirm that, during the period of my stay in the university, I will not engage in or
encourage any form of anti-social behavior including ragging (torture) and that I will pay due
respect to the teachers and officials and that I will not engage in any act that will harm the goodwill
of the university.
I am fully aware that I am liable for suspension from the university and for any other
disciplinary action if I am unable to abide by the bylaws of this act.
Signed this on the ………………………. day of the month of ………………………… the year
……………………..

………………………………….
Signature of the Student/Applicant

STUDENT ENROLMENT FORMS SECTION - I Page 2 of 4 Pages - (24)

 I hereby certify that this student/applicant, who is known to me personally, has enclosed all information
relevant to this enrolment form correctly and that he/she signed this application in my presence.
Name of the Student/Applicant

National Identity Card No. of the

Applicant
Signature of the Student/Applicant

Name of the Justice of Peace/Commissioner for Oaths/Principal of the School of the applicant

Signature of the Justice of Peace/Commissioner for

Oaths/Principle of the School of the applicant

Official Stamp of the Justice of Peace/Commissioner

for Oaths/Principle of the School

Undertaking by the Parent/ Guardian

1. I, ………………………………………………………………….(Name of Parent/Guardian) have

carefully read fully understood the law prohibiting ragging in the prohibition of Ragging and Other
Forms of Violence in Educational Institutions Act, No. 20 of 1998.
2. I assure you that my son/ daughter/ ward will not indulge in any form of ragging.
3. I hereby agree that if he/she is found guilty of any form of ragging he/she may be punished as
per the law enforced and by-laws of the University.

……………………………………..
Signature of Mother/ Father/ Guardian

Name :……………………………………………………………………………………………………….

Relationship to the student: …………………………..……………………………………….

Address: ……………………..……………………………………………
…………………………..………………………………………
…………………………..………………………………………

STUDENT ENROLMENT FORMS SECTION - I Page 3 of 4 Pages - (24)

14. The Students, who wish to be enrolled with this University, are required to pay the enrolment fee as
follow.

Category Enrolment Fee

If a student of Medicine/Applied Sciences/Technology or Rs. 1,900/=
Agriculture faculties.
If a student of Management or Social Sciences & Humanities Rs. 1,400/=
(Arts) faculties.

The paying-in voucher which can be downloaded from the https://payment.rjt.ac.lk/student/ , should be
used in paying of University enrol l m ent fee. Stu dents can use any mode of paym ent o p t io ns
f rom t he fol l owi ng
OP1. Online payment using Credit Card or Debit Card by login on to https://payment.rjt.ac.lk web site
Note: use your email as username and click forgot password option to get your login password.

OP2. Money transfer using internet banking facilities provided by the Bank of Ceylon or People's Bank.
Note: Student should remark the 'PIV no' in the description field provided by the banking app
OP3. Counter payment at any of the Bank of Ceylon branch in Sri Lanka
OP4. Counter payment at any of the People's Bank branch in Sri Lanka
Note: Student must complete date & signature in the paying-in voucher before proceeding counter payment.
Bank copy of the voucher will be retained by the bank. The University copy and the student copy with bank
i mpri nt will be returned t o you by the bank on compl et i on of t he payment.

Paste the duly endorsed bank voucher (payment slip) received on payment of enrolment fee.

STUDENT ENROLMENT FORMS SECTION - I Page 4 of 4 Pages - (24)

 Form No.: SR-02

Rajarata University of Sri Lanka

Special Skills of Students

Registration No National Identity Card No or

Passport No:

01. Name of the Student (with initials) : …………………………………………………….....

02. Hobbies : ……………………………………………………….

……………………………………………………….
……………………………………………………….

03. (a) Sports

Athletics Events Details of the sports Year Place/Awards

participated festival
(with details)

1. …………………………… ………………….…………. ………………………………… ……………. ……………………….…

2. …………………………… ………………….…………. ………………………………… ……………. ……………………….…
3. …………………………… ………………….…………. ………………………………… ……………. ……………………….…
4. …………………………… ………………….…………. ………………………………… ……………. ……………………….…

(b) Indoor Games/ Sports

1. …………………………… ………………….…………. ………………………………… ……………. ……………………….…

2. …………………………… ………………….…………. ………………………………… ……………. ……………………….…
3. …………………………… ………………….…………. ………………………………… ……………. ……………………….…
4. …………………………… ………………….…………. ………………………………… ……………. ……………………….…

(c) Outdoor Games/ Sports

1. …………………………… ………………….…………. ………………………………… ……………. ……………………….…

2. …………………………… ………………….…………. ………………………………… ……………. ……………………….…
3. …………………………… ………………….…………. ………………………………… ……………. ……………………….…
4. …………………………… ………………….…………. ………………………………… ……………. ……………………….…

04. Art skills (Drawing, Sculpture)

Art Exhibitions held Year Certificates received

1. …………………………….…… …………………..……………….…………. ……………. ……………………….………….

2. …………………………….…… …………………..……………….…………. ……………. ……………………….………….
3. …………………………….…… …………………..……………….…………. ……………. ……………………….………….

STUDENT ENROLMENT FORMS SECTION - II Page 1 of 4 Pages - (24)

05. Music Skills
1. Skills related to playing instruments

Instrument you can Musical programmes/Shows Year

play participated

1. ………………………………………. ………………………………………………………………….. ………………………………….

2. ………………………………………. ………………………………………………………………….. ………………………………….
3. ………………………………………. ………………………………………………………………….. ………………………………….

2. Singing Skills

1. ………………………………………. ………………………………………………………………….. ………………………………….

2. ………………………………………. ………………………………………………………………….. ………………………………….
3. ………………………………………. ………………………………………………………………….. ………………………………….

Singing medium:………………………………………………….

06. Dancing Skills

Dancing Events participated Year Certificates/awards received

category

1. …………………………… ………………………………………………… …………… ………………………………………………

2. …………………………… ………………………………………………… …………… ………………………………………………
3. …………………………… ………………………………………………… …………… ………………………………………………

07. Performing Skills

Drama, Films, Character performed Direction Year of

Teledrama participated production

1. …………………………………………. ………………………………………… ……………………………… ……………………

2. …………………………………………. ………………………………………… ……………………………… ……………………
3. …………………………………………. ………………………………………… ……………………………… ……………………

08. Any events, exhibitions, drama, you have organized under No.3, 4,5,6,7

1. …………………………………………. ………………………………………….. ……………………………… ……………………

2. …………………………………………. ………………………………………….. ……………………………… ……………………
3. …………………………………………. ………………………………………….. ……………………………… ……………………

STUDENT ENROLMENT FORMS SECTION - II Page 2 of 4 Pages - (24)

09. Oratory skills

Orations, debates Details of the events Year Certificates/awards

participated receives

1. …………………………………………. ………………………………………….. ……………… …………………………………….

2. …………………………………………. ………………………………………….. ……………… …………………………………….
3. …………………………………………. ………………………………………….. ……………… …………………………………….
4. …………………………………………. ………………………………………….. ……………… …………………………………….

10. Leadership-Positions held in committees, associations in school and village

Position Institute/Organization Period Service extended

1. …………………………………………. ………………………………………….. ……………… …………………………………….

2. …………………………………………. ………………………………………….. ……………… …………………………………….
3. …………………………………………. ………………………………………….. ……………… …………………………………….
4. …………………………………………. ………………………………………….. ……………… …………………………………….

11. Writing Skills (Novels, Poetry, Articles, papers published)

Title of the publication News paper/ Medium Year

Magazine/Journal

1. …………………………………………. ………………………………………….. ……………………………………. ………………

2. …………………………………………. ………………………………………….. ……………………………………. ………………
3. …………………………………………. ………………………………………….. ……………………………………. ………………
4. …………………………………………. ………………………………………….. ……………………………………. ………………

12. Please indicate other skills (Mention your production/Creative abilities)

……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………..

13. Details of occupation done after leaving school.

Institute Post Services offered period
from-to

1. …………………………………………. ………………………………………….. ……………………………………. ………………

…………………………………………. ………………………………………….. ……………………………………. ………………

2. …………………………………………. ………………………………………….. ……………………………………. ………………

…………………………………………. ………………………………………….. ……………………………………. ………………

STUDENT ENROLMENT FORMS SECTION - II Page 3 of 4 Pages - (24)

14. Details of self employment, joint ventures or other business engaged in full time or
part time during the studies or after leaving school.

Business Service rendered Monthly turn Your

over monthly
income

1. …………………………………………. ………………………………………….. ……………………………. ………………

…………………………………………. ………………………………………….. ……………………………… ………………

2. …………………………………………. ………………………………………….. ……………………………… ………………

…………………………………………. ………………………………………….. ……………………………… ………………

3. …………………………………………. ………………………………………….. ……………………………… ………………

…………………………………………. ………………………………………….. ……………………………… ………………

Date: ……………………….. ……………………….…………………

Signature of the Student

STUDENT ENROLMENT FORMS SECTION - II Page 4 of 4 Pages - (24)

 Form No.: SR-03
Rajarata University of Sri Lanka
Mihintale
Application for the Student Identity Card

01 Registration No :- …………………………………...… 02. Admission Year:- 2022/2023

03. National Identity :- ……………………………………………

Card or Passport No:

04. Course of Study :- …......................……………………………………………………………

05. Full Name in English :- ……………………………..………………...............………………….…

as per the National ……………………………..………................……………………………
Identity Card ……………………………..………................……………………………

06. Full Name in Sinhala :- ……………………………..………………...............…………………….

or Tamil ……………………………..………................……………………………
……………………………..………................……………………………
07. I. Title :- (Mr./Ms./Rev./Other) …………………….……

II. Name with :- ……………………………..………................……………………………

Initials

08. Telephone No. :- ………..……..................... E-mail:……...............….…………………….

09. Permanent Address in English :- ……………………………………………………………….....

: ………………………………………………………………………………………….
: ………………………………………………………………………………………….

10. Permanent Address: ………………………………………………………………………………......

in Sinhala or Tamil ………………………………………………………………………………......
………………………………………………………………………………......

11. Postal Address: ………………………………………………………………………………......

If there is a difference from
permanent address ………………………………………………………………………………......

12. Photo 13. Signature

Pas te a colou r
photograp h of the
applic ant

Size: 4cm x 5cm

Please place your regular signature inside the cage
above. Signature should not touch the border.

STUDENT ENROLMENT FORMS SECTION - III Page 1 of 2 Pages - (24)

 Form No.: SR-04

Rajarata University of Sri Lanka

Application for the Residential Facilities

Index No. (2022 A/L) :………….………..……….

Registration No : ………………………….………
^ For office use only&
All incomplete applications will be rejected. Information should be furnished under each number
otherwise mention inapplicable. When it is necessary mark “X” on the relevant cages. If you request
residential facilities under medical grounds, such medical certificates should be submitted along with
this application. Medical certificates submitted thereafter will not be accepted under any circumstances.

Closing date of the applications: Refer to the covering letter

(Application after the due date will not be considered)

1. a) Name with initials :……………………………………………………….………………….

………………………………………………………..………………….

b) Name in full :……………………………………………………….………………….

………………………………………………………..………………….

c) Telephone Nos. Land :………..…….…..…. Mobile:………..…….……

2. Sex: : Female Male

3. Civil Status : Married Unmarried

4. NIC No. : ………………………………………

5. Faculty : ………………………………………

6. Permanent Address : …………………..………………………………………………….

…………………..………………………………………………….
…………………..………………………………………………….

7. District : …………………………… Electorate : ……..…………..……………

8. a) Closest town situated on the way to the university :……………………..……………

^Distance should be mentioned in Kilometers&

b) Distance from the permanent residence to this town in kilometers:….…….………………

c) Distance from the permanent residence to the University: …………………….…………...

9. Address for correspondences (If it is : ……………………………………..…………..

different from permanent address) ………………………………..………………..
………………………………..………………..
………………………………..………………..
………………………………..………………..

4 STUDENT ENROLMENT FORMS SECTION - VI Page 3 of 6 Pages - (24)

 10. Address of father/mother/guardian : …..……………………………………………..
………………………………..………………..
……………………………..…………………..
……………………………..…………………..
11 Annual income of parents : ……………………………..…………………..
(Income report certified by the Grama Niladhari should be attached)

12. If you are employed, :

a) Designation:………………………………………………………

b) Address of the place of employment

……………………………………….………..
……………………….….……………………..
…………………….…….……………………..

13. Any other reason which helps to consider for :………………….……………………………..

residential facilities (such requests should be …………………..……………………………..
certified by the Grama Niladari) Appeals …………………..……………………………..
should
be attached separately. …………………..……………………………..

I do hereby certify that the particulars given by me are true and correct to the best of my
knowledge and I agree to follow rules and regulations stipulated by the university, if I am
selected for residential facilities, I agree to inform the university and vacate hostel if I get
married or found employment.

………………………………….
Date:………………………….. Signature of the Student

Recommendation of Grama Niladhari

I do hereby certify that the particulars given under Nos. 1, 3, 4, 6, 7, 8, 9, 10, 11, 12,13 are
true andcorrect to the best of my knowledge.

………………………………….
Date :………………………….. Signature of Grama Niladhari

(Official frank)

4 STUDENT ENROLMENT FORMS SECTION - VI Page 3 of 6 Pages - (24)

 Form No.: SR-05

Admission Year: 2022/2023

DEPARTMENT OF PHYSICAL EDUCATION
RAJARATA UNIVERSITY OF SRI LANKA
STUDENTS’ PHYSICAL ATTRIBUTES & SPORT ACHIEVEMENTS
Student …………........................................... National Identity ........................................
Registration No:
Card No or
Passport No:
01. Full Name (Mr./ Mrs./ Miss.) : …………………………………………………………...
…………………………………………………………...
02. Faculty : …………………………………………………………...

03. Weight : …………………………………………………………...

04. Height : …………………………………………………………...

05. Date of Birth : …………………………………………………………...

06. Permanent Address : …………………………………………………………...

…………………………………………………………...
…………………………………………………………...

07. District : …………………………………………………………...

08. Contact No. : Residence :……………………………………
Mobile :……………………………………

09. Education Detail :

Name of the School From To
1. ………………………………………………………………… …………………………………
2. ………………………………………………………………… …………………………………
3. ………………………………………………………………… …………………………………
10. Sports Achievement :
Year Sports Level (School/ Achievement
District/ Province/
National/
International
1. …………………... …………………………. ………………. …………………………….
2. …………………... …………………………. ………………. …………………………….
3. …………………... …………………………. ………………. …………………………….
4. …………………... …………………………. ………………. …………………………….
5. …………………... …………………………. ………………. …………………………….
6. …………………... …………………………. ………………. …………………………….

11. Other Qualification :

…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
Date: ………………………………. Signature of the Student: …………………………….
4 STUDENT ENROLMENT FORMS SECTION - VI Page 3 of 6 Pages - (24)
 Form No.: SR-06

Rajarata University of Sri Lanka

Application for Bursary
Please read this carefully before attempting to fill your response.

Eligibility criteria for applying bursaries

Parental annual income should be equal or less than to Rs. 500,000/=

The following concessions to be added to the Income Ceilings specified above.
a) Rs. 24,000/= concession per annum per school going sister/brother who is 19 year or under, up to maximum
of three children.
b) Rs. 36,000/= per annum per school going sister/brother following a course in a University but not in receipt of
a Mahapola scholarship or a Bursary.

Only students, who are eligible according to the above criteria for bursary, should proceed (apply) through
the following steps (Others should not require to complete and return this form)

Condition governing the payment of Bursaries

1. Any student who provides false, inaccurate statement or who fails to disclose any material fact in his/ her
application is liable to have his/ her enrolment as an internal student cancelled.
2. The student who have applied for a Bursary or who are in receipt of Bursary should communicate in writing to
the Registrar of the University in receipt of any changes of family income, marital status, employment income
etc.
3. The Bursaries will be paid only during period of study in the University. The recipient of Bursary who for any
reason temporarily ceases to follow the course of study or leaves the University before completion of study,
should communicate that fact in writing to the Registrar of the University as the case may be.
4. The payment of a Bursary to any student may be completely stopped or temporarily suspended for any one
or more of the following reasons;
a) The Bursary may be paid to any student who has been referred at the first year examination and who is
following the course prescribed for the second year.
b) If the student fails to take any examination at the first available occasion for any reason which is not
acceptable by the Vice Chancellor.
c) If the student conducts himself in an indiscipline manner.
d) For any other valid reason, to be decided upon at the discretion of the Vice Chancellor.

5. University authorities have their discretion on matters relating to the restoration of Bursaries, which have
been stopped or temporarily suspended.
6. Each eligible student will be paid maximum of 10 monthly installments per academic year.
7. Conditions applicable to Mahapola scholarships are generally applicable to Bursaries too.
8. If you are in receipt of Mahapola scholarship, you will not be awarded the Bursary.
9. Under no condition duplicate Bursary form will be issued.

4 STUDENT ENROLMENT FORMS SECTION - VI Page 3 of 6 Pages - (24)

 Instruction to the Applicant

1. All details asked for regarding all avenues of income must be mentioned. Information supplied by regarding
your income will be verified form relevant officials and the Department of inland Revenue. Documents,
relevant to the information sought for under No. IV of the application form regarding details of salary
under annual gross income of parents Pension Certificates, Death Certificates, Detail of pension, Income
of House, Property and Business Enterprises must be attached to the application form.

2. No cage must be left blank or closed by lines. Where is no relevant information to be supplied, that must
be so mentioned. Incomplete forms, applications received later than due date and application not sent
through the Grama Niladhari and Divisional Secretary will be rejected.

3. This application must be duly completed, and handed over to the Grama Niladhari of the area with the
relevant documents to enable him to be received on or before the deadline specified in the covering letter
of enrolment. The Grama Niladhari will (as per cage Viii) send it through the Divisional Secretary in time as
required. As the Bursary form needs to be sent by registered post, an envelope (6’’x9”) stamped to the
value of Rs.55.00 (or postage according to the weight) on which the University address written must be
handed over to Grama Niladhari with application form. Under no circumstances must the application form
be returned by the applicant.

4. It must be clearly understood that if the University authorities are convinced that the information
provided one the application form is false, legal action will be taken against you, or even your internal
studentship will be cancelled

5. All decisions regarding the award of the Bursary, rejection of the Bursary, or discontinuing are made by the
University. Therefore, please note that request regarding Bursaries must not be made by the University
Grants Commission, and such requests will not be responded.

6. *All applicants shall have/open a new bank saving account at the Bank of Ceylon reserved for bursary
transaction. The photocopy of the passbook, showing the account number, shall be attached along with
the bursary application.

4 STUDENT ENROLMENT FORMS SECTION - VI Page 3 of 6 Pages - (24)

 (for office use only)

I.
1. Student Full Name :Rev./Mr./Ms. ……………………………………………………………………………………

……………………………………………………………………………………………………………
2. Name with initials :……………………………………………………………………………………………………………

3. NIC Number : ……………………………………………………………………………………………………………..

4. Faculty :……………………………………………. Academic year :……………………………………

5. Registration No :…………………………………………………………………………………………………………...

6. Permanent Address :……………………………………………………………………………………………………………

……………………..………………………………………………………………………………………..

……..………………………………………………………………………………………………………..

7. Telephone No :Land…………………………………………..Mobile…………………………………………….

8. Grama Niladari Division :…………………………………………………………………………………………………….

9. Divisional Secretariat Division :…………………………………………………………………………………………..

10. District :…………………………………………………………………………………………………………….

11. BOC Account No :…………………………………………………………………………………………………………….

(Should be attached BOC pass book copy)

II. Distance from permanent residence (i.e. your home to the Rajarata University of Sri lanka to the
closest Kilometer ................................................ km.

4 STUDENT ENROLMENT FORMS SECTION - VI Page 3 of 6 Pages - (24)

 III. Details of Family:
STUDENT ENROLMENT FORMS SECTION - VI

Enter here the details of Mother, Father, brothers and sisters or guardian. If required, you must be able to submit the relevant birth certificates.

Name with initials Date of School/Institute/HEI Grade/ Course Acdemic year or Reg. Mahapola /Bursary
Birth No or any
Page 4 of 6 Pages - (24)
 IV. Details of Family income
STUDENT ENROLMENT FORMS SECTION - VI

Provide the gross annual income of mother, Father, and Unmarried Brothers & Sisters. Certified pay sheets should be attached.

Name with initials Relationship

Employment Property Total
(to applicant)
Gross
place Designation Land House other
income
1.

2.

3.

4.

5.

6.

Total
Page 5 of 6 Pages - (24)

V. Declaration by the Applicant:

I certify that the above particulars furnished by me are true and correct to the best of my knowledge, and that I do not pay any income tax. Further, I affirm that in
the event of any of the above particulars being proved false or inaccurate to the University Authorities. I am liable to be punished according to the Clause 4 of the
instructions given to the applicants as above.

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

Signature of Applicant
VI. INSTRUCTION TO GRAMA NILADHARI AND DIVISIONAL SECRETARY

1. Special attention must be paid to the average income of the applicant from houses and property
according to the general situation of the area and the details provided by him/her under III and IV
regarding the income from houses and property. You have to make a declaration with reference to the
details provided by the applicant regarding his/her sisters and brothers, the parental income entered
under IV above, and the authenticity of the supporting documents and certify accordingly.
2. The application thus certified by you must be forwarded to the Divisional Secretary. Under no
circumstances must you ever hand over the application to the applicant.
3. The document forwarded by the Grama Niladari, must be counter signed (certified) and sent by the
Divisional Secretary under registered post to each the following address as soon as possible. For the
postage, postal stamp worth Rs.55/= affixed on envelope of 6”x9” in size, which the following address is
written will be provided by the applicant along with the application.

Postal Address:
Asst. Registrar, Student Services Division, Rajarata University of Sri Lanka, Mihinthale.
T.p. 025 2266577 (Student Services Division)

VII. Name of Grama Niladhari : ..............................................................................................................

Name and area of the

Grama Niladhari : ...............................................................................................................
Annual income of parents/ Guardian Rs. : ..............................................................................................

I have compared the annual income of the parents/ Guardian shown cage III and IV and the details of
houses and property owned by the sisters and brothers with the documents submitted to me and I certify
them to be correct according to the best of my knowledge and belief.

Date: ............................... .......................................................

Signature of the Grama Niladhari
Official Stamp

VIII. Certify that the above information are correct

Name of Divisional Secretary :..................................................................................................................

Signature of Divisional Secretary : .............................................................................................................

Official Stamp of Divisional Secretary : ....................................................................................................

Division : ............................................. Post Office : ..............................................

Date : .........................................

STUDENT ENROLMENT FORMS SECTION - VI Page 6 of 6 Pages - (25)

 Form No.: SR-07

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Rajarata University of Sri Lanka Mihintale Sri Lanka

STUDENT REGISTRATION DIVISION

Vice Chancellor: 025-2266644 Registrar: 025-2266511 Asst. Registrar (Registration)
Telephone (General): 025-2266643, 2266645, 2266646 Tel / Fax: 025 – 2266744, Ex: 2141

My Ref: RJT/EXA/STR/2024/01
Date: 19/02/2024
Director, General Hospital
Medical Officer, District Hospital/ Base Hospital

Dear Sir/ Madam,

Medical Examination for University Enrolment

A complete medical examination with basic investigation is mandatory for all new entrants seeking
admission to Rajarata University of Sri Lanka. However, with the very large number of students
who are seeking entry, it is an impossible task to complete these medical examinations at the
University Medical Centre before they are admitted to the University.

Moreover, once admitted, there is very poor student response for routine medical examinations.

The need for medical examination before admission has been found to be more important since
several students with major handicaps have been discovered long after entry to the University.

Therefore, I am compelled to seek your kind assistance in this matter. Every student will be advised
to report to the nearest District/ Base/ Provincial Hospital for this medical examination.

Please be so good as to complete the attached form and send it under confidential cover to
reach the following address, on or before 04th March 2024.

Medical Officer
Medical Centre
Rajarata University of Sri Lanka
Mihintale

Thank you for your kind corporation.

Yours faithfully,

Deputy Registrar/Student
Registration For Registrar

STUDENT ENROLMENT FORMS SECTION - VII Page 1 of 6 Pages (24)

 Form No.: SR-07

Rajarata University of Sri Lanka

Medical Examination Report

Student’s Registration No:…………………………….

This information is strictly for the use of University Health Service, and will not be released to
anyone without your knowledge and consent.

Part I of the form should be completed by the student and Part II should be completed by a Doctor
registered with the Medical Council of Sri Lanka and it should be signed and stamped.

Part I (To be filled by the student)

Full Name : ……………………………………………………………………………………….……

……………………………….……………………………………………………………
Faculty : ………………………………..……….…………………………………………..………
N.I.C. No. : ………………………..……………...……………………………………………………
Age : …………. Sex : Male Female Sri Lankan Foreign
Married
Religion : …………………… Civil Status : Single
Language Competences : Sinhala Tamil English
Last School Attended : …………………………………………………………………………………………….
Occupation of Father : …………………………………………………………………………………………….
Home Address : …………………………………………………………………………………………….
…………………………………………………………………………………………….
…………………………………………………………………………………………….
District : …………………………………………………………………………………………….

Extra Curricular Activities during the School day:

: Sports Yes No If yes indoor games/ outdoor games

Music Yes No

Dancing Yes No

Art Yes No

Religious Work: Yes No Leadership Yes No

Person to notify in case of emergency:

Name : ………………………………………………………………
………………………………………………………………
Address : ………………………………………………………………
………………………………………………………………

………………………………………………………………
Telephone Nos. : Land :……………………….. Mobile:…………………….

Relationship : ………………………………………………………………

STUDENT ENROLMENT FORMS SECTION - VII Page 1 of 6 Pages (24)

 Family Medical History :
ALIVE Dead/ Age at Cause of
Age State of Health if Death Death
ill, mention the
illness
Father
Mother
Brother/ Sister
Brother/ Sister
Brother/ Sister

Student Medical History: Have you suffered from any of the following:
Infectious diseases : Mumps Yes No
Measles Yes No
Polio Yes No
Rubella Yes No
Infective Hepatitis Yes No
Whooping Cough Yes No
Chicken Pox Yes No
Tetanus Yes No
Diphtheria Yes No
Sexually Yes No
transmitted disease
Others (Specify) : …………………..

Worm Infestation : Filarial Yes No

Others Yes No

Tropical Diseases : Malaria Yes No

Amoebic Dysentery Yes No
Dengue Yes No
Bacillary Dysentery Yes No
Others (Specify) : …………………..

Respiratory System : Frequent Colds Yes No

Hay Fever Yes No
Asthma Yes No
Pneumonia Yes No
T.B. Yes No
Others (Specify) : …………………..

Circulatory System : Heart Disease Yes No

High Blood Pressure Yes No

STUDENT ENROLMENT FORMS SECTION - VII Page 1 of 6 Pages (24)

 Nervous Breakdown Yes No
Nervous System : Epilepsy Yes No
Migraine Yes No
Others (Specify) : …………………..

ENT : Ear Infections Yes No

EYE : Short Sight Yes No

Long Sight Yes No

Surgical : Fractures Yes No

Operations Yes No

Immunizations : Have you been Yes No

vaccinated against
Diphtheria, Tetanus,
Whooping Cough,
Polio, Typhoid,
T.B./B.C.G.

Mental Health : Have you any stress Yes No

related problem
Depression Yes No
Exam anxiety Yes No
Suicidal attempt Yes No

Menstrual history : Period : Regular/ irregular flow slight/

normal/ excessive pain

Misc : High Blood Pressure Yes No

Diabetic Yes No
Alcohol/Drugs Yes No
Tobacco/Cigarette Yes No
Allergies (Specify) …………………..

Disability : Do you believe that you have a disability that any

way requires you to receive special
consideration from the University. If so please
indicate the type of disability and givea brief
description below;
……………………………………………………
……………………………………………………
……………………………………………………
……………………………………………………

I here certify that the information furnished by me is true and accurate.

Date:…………………… ………………………………………..
Signature of the Student

STUDENT ENROLMENT FORMS SECTION - VII Page 1 of 6 Pages (24)

 Form No.: SR-07
Medical Examination Form Part II to be filled by the Medical Officers

Student Registration Number

Name of Applicant
Date of Examination
Height cm Weight kg
Vision Right eye Left eye
Without lenses 6/ 6/
With lens 6/ 6/

Physical Examination
Pulse per minute Systolic Diastolic
Blood Pressure
Ears Right Left
Hearing Right Left
Nose
Throat
Teeth Decayed extracted filled Gingivitis Dentures

Skin
Lymph glands
Thyroid
Abdomen Heart
Hernial orifices Lung “X” ray
Genitalia and anus
Any other defect
Psychosomatic sings
Referred to
Eye Surgeon
Dental Surgeon
ENT Surgeon
General Surgeon
Orthopedic Surgeon
Physician
Chest Physician (“X” ray)
Psychiatrist
Skin Specialist
Gynecologist
Obstetrician
Urine
Albumen
Sugar
Other examination

Date:………………………… …………………………………………………
Initial of Examiner Official Frank

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