Application for Scholarship/Course
*
are mandatory fields and need to be filled
1.0 Please tell us about yourself
Surname:
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Name:
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Date of Birth:
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NIC No:
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Gender:
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Please Select
Male
Female
Unspecified
Impairment:
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Please Select
Autism
Intellectual Impairment
Hearing Impairment
Visual Impairment
Orthopedic Impairment
Speech/Language Impairment
Specific Learning Disabilities
Serious Emotional Disturbances
Multiple Disabilities
Major health Impairment
Others
Specify:
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2.0 Your Contact Details
Address:
Telephone:
Residence:
Mobile:
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Email:
3.0 Purpose of Application
Francois Sockalingum Award
Training
4.0 Education Level
CPE
SC
HSC
Vocational Training
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Special Training
Diploma
Degree
Other
Specify:
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4.0 Declaration
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I hereby declare that I have read, understood and agree to the Terms and Conditions of MAUSHIELD. I also declare that the particulars in this application are genuine, accurate and that I have not willfully suppressed any material fact. I acknowledge that any false information could lead to the dismissal of the membership.
