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"
(9" x 4 1/ 2")

For office use only
Application No. District
SPECIMEN APPLICATION FORM

Institute of Technology, University of Moratuwa

APPLICATION FOR ADMISSION TO THE NATIONAL DIPLOMA
IN TECHNOLOGY COURSE ACADEMIC YEAR 2003/ 2004
Application for
(a) Maritime Fields (SET 1)
(b) Other Fields
(SET 2)
(Please tick ( ) One or Both)
(See item 12 for details of fields in SET 1 and SET 2. Application fee
for SET 1 or SET 2 is Rs. 150 / for SET 1 and SET 2 is Rs. 300)
(All cages must be completed in English Block Capitals only)
1. Last Name of Applicant :
2. Initials :
3. Names denoted by Initials :

4. Contact Address :.......................

(Please enclose two self-addressed 9"x41/2" envelopes)
5. Telephone No. :................................................
6. Date of Birth :

Year

Month

Date

(Please enclose a certified copy of the Birth Certificate)

7. Are you below 24 years on closing date ? Yes No
Please tick ( )
8. National Identity Card No. :
(Please enclose a certified copy of the ID Card)
9. Sex :

10. Results of G. C. E. (Advanced Level) Examination :

(Please enclose certified copies of G. C. E. (A/L) and Aggregate/
Z-Score Certificates for each of the attempts)
Subjects &
Details of
Examination

Grades & Details

obtained at the
Year : 2000 Year : 2001 Year : 2002

Physics
Chemistry
Pure/Combined
Mathematics
Applied /
Advanced
Mathematics
Index No.
Medium
(Sinhala or
Tamil)
Aggregate/
Average Mark
or Z-Score
G. C. E. (A/L)
under New or
Old scheme

"
"
[ - 2004

Results of year to be considered

for Selection (indicate
whether 2000 or 2001 or 2002)
11. School(s) attended from Year 11 to 13 :
(Please enclose a certified copy of the school leaving
certificate)
Year Name & Address Administrative
of School
District

Period of
Attendance
From
To
Y MD Y MD

11
12
13
1st
Attempt
2nd
Attempt
3rd
Attempt
12. Field Preference :
SET 1 Insert order of preference as 1 for First preference
and 2 for Second preference.
This should be completed only by the candidates who
have applied for Maritime Studies.
SET 2 Insert order of preference as 1, 2, 3, 4, 5, 6, 7, "1"
for the "most preferred", "2" for the next, and so on "7"
for the last preferred.
SET 1
Maritime Fields
Marine Engineering Technology
Nautical Studies and Technology

Prefer.

(Special Medical Test and Interview for SET 1)

SET 2
Other Fields
Chemical Engineering Technology
Civil Engineering Technology
Electrical Engineering Technology
Electronics & Telecom Engineering
Technology
Mechanical Engineering Technology
Polymer Engineering Technology
Textile & Clothing Technology

Prefer.

Male
Female
Please tick ( )

13. Applicant's Declaration :

(i) I declare that I am not a fultime registered student at
any University (except open University of Sri
Lanka) or any Higher Educational Institution under
the Ministry of Tertiary Education and Training.
(ii) I certify that all the particulars given by me in this
application are true and accurate. I am aware that if
any particulars given by me in this application are
found to be false or inaccurate prior to my admission,
my application will be rejected and that if such
information is foud to be false or inaccurate after
my admission, I will be discontinued from the
course.
(iii) I am aware that if certified copies of Birth, G. C. E.
(A/L), Aggregate/Average/ Z-Score, School Leaving
Certificates and certified copy of the National ID
are not included with the application under any
circumstances, the application will be rejected.
(iv) In the event of my being slected for admission after
the Test, I shall abide by the Statutes, By-Laws,
Regulations and Rules of the Institute of Technology,
University of Moratuwa in so far as they are
applicable to me.
(v) I have enclosed a receipt obtained from a branch of
Bank of Ceylon, drawn in favour of "Institute of
Technology, University of Moratuwa, Account No.
300801412 of Bank of Ceylon - Katubedda Branch"
to a value of Rs. .................................... . I also
enclose two self-addressed envelopes.
..........................................................
Signature of Applicant.
Date :................................
5-392

State Priority, if applied for both sets :

SET 1
SET 2
Please tick ( )

[
+

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