Personal Record and Financial Information

THE COMMITTEE ON HIGH POSTS OF THE PARLIAMENT OF SRI LANKA TO EXAMINE THE SUITABILITY OF PERSONS NOMINATED / APPOINTED TO THE STATE SERVICES AND STATE CORPORATIONS

Name :

Position :

Date of appointment to the present position :

Ministry :

Salary Scale :

(A) BIOGRAPHICAL INFORMATION

1. Name in full :

2. Address :

(a) Official : Telephone No :

(b) Private : Telephone No :

(c) Mobile No :

(d) Email :

3. (a) Date of birth and age :

(b) Place of Birth : (c) N.I.C. No :

4. Marital Status :

5. Citizenship :

6. Names and ages of children :

7. (a) Spouse’s post, place of employment and salary, if employed :

1 (b) Particulars of children’s employment, if any :

2 8. Education (Include institutions attended and dates) : (Academic)

Period Grade/Examination Passed Educational Institution From To

(Professional) Period Name of Course Educational Institution From To

9. Employment Record : (List all posts held since leaving school, with relevant dates including title or description of post, name of employer, location of work)

Period Post held Institution From To

10. (a) Last post held and salary drawn :

3 (b) Write a short description of any progress you have been able to show while serving in a similar position previously:

11. Memberships : (List all memberships and offices held in professional, fraternal, civic, charitable and other organizations)

12. Honours and Awards: (List Scholarships, special recognition for outstanding service, etc)

13. Publications:

(B) FINANCIAL DATA

( To be furnished as per annexure)

(C) FUTURE EMPLOYMENT RELATIONSHIPS

1. Will you sever all connections with your present employers, business firms, business associations or business organizations if your proposed appointment is confirmed?

4 2. Has anybody made a commitment to employ your services in any capacity after you leave your proposed assignment?

5 (D) POTENTIAL CONFLICTS OF INTERESTS

1. Describe all your financial arrangements, and other continuing dealings with business associates, clients or customers.

2. Indicate any investments, obligations, liabilities or other relationships of yours, your spouse’s your children’s which could involve potential conflicts of interests in the position to which you have been nominated.

3. Describe any business relationship, dealing or financial transaction which you or your spouse have had during the last ten years, whether for yourself, on behalf of a client, or acting as an agent that could in any way constitute or result in a possible conflict of interest in the position to which you have been nominated.

4. Explain how you will resolve any potential conflict of interest, including any that may be disclosed by your answers to the above items.

(E) OTHER

1. Have you ever been convicted of any criminal violation other than minor traffic offences ?

2. Have you ever been found guilty of any fundamental rights violations before the Supreme Court ?

3. Please advise the Committee of any additional information, favourable or unfavourable, which you feel should be considered in connection with your nomination.

I ……………………………………………………………………… do hereby declare that the answers given and statements made by me herein are true and accurate.

Date : ………………………… Signature

Note : If any of the columns in this form are insufficient for the particulars required such particulars may be given in a separate schedule or schedules provided that appropriate reference is made to any such accompanying schedule is in the questionnaire.

6 ANNEXURE

DECLARATION OF ASSETS AND LIABILITIES

Please furnish a statement answering to the requirements in the appended form and giving all details of your wealth as at ………………………………………………….

1. If married, name of spouse : ………………………………………………………………

2. If spouse is employed his/her salary and allowances per month : ………………………...

3. Does anyone hold any property in trust for you, your spouse or any of your children * . If so, give full particulars including name, extent and situation of property, date and cost of acquisition.

4. Do you, your spouse or any of your children * hold any property in trust for any one ? If so give full particulars as called for in above.

5. Income Tax file number : …………………………………………………………………….

6. Do you, your spouse or any of your children * have any Accounts (Current Accounts, Savings Accounts, Fixed Deposits etc. ) in any Banks in Sri Lanka or abroad including Post Office Savings Bank and National Savings Bank ? If so, state –

Name and Name of Account Number Date on which Balance at address of Bank Account Holder account was prescribed date opened

7 7. Have you, your spouse or any of your children * invested any money in Savings Certificates, Tax Reserve Certificates or Government Securities ? If so, state –

Name of Holder of Number of Date and Place of Amount of Investment Certificate Certificates Issue

8. Have you, your spouse or any of your children * loaned any money to any individual company or Partnership on Promissory notes, cheques or other security or on the hypothecation of movable or immovable property ? If so, state –

Name and Date and Rate of interest No. and Date of Name of Notary address of Amount loaned Deed Borrower

9. Do you, your spouse or any of your children * hold any stocks, shares or debentures ? If so, state -

Name of Name and Number of Purchase value Date of purchase Shareholder Address of shares held of shares Company

10. Have you, your spouse or any of your children* invested any money in any business venture ? If so, give full particulars of such investment including date and amount invested.

8 11. Have you, your spouse or any of your children * any assets abroad ? If so, state the name of the country, nature and value of such assets and date of investment.

12. Give details of your cash with you or in the custody of any other person at the prescribed date and state amount and name and address of such person.

13. Have you, your spouse or any of your children * a safe deposit vault in any Bank ? If so, state name and address of Bank, date on which such vault was rented out, contents and their value at prescribed date.

14. Do you, your spouse or any of your children* own or possess jewellery, precious stones (cut or uncut), gold or silver ? If so, give description of such articles.

15. Do you, your spouse or any of your children* own any motor vehicles, motor boats or other power driven vehicles ? If so, state -

Type of vehicle Make Registration No. Date of Purchase Price paid

9 16. Give full particulars of all immovable property owned or possessed by you, your spouse or any of your children * as at the prescribed date

Name of Situation Extent By How Date & Name Consideration Whether Nature of Cost of land of land whom acquired No. of of agricultural buildings Construction acquired (Gift or Deed Notary or bare land purchased)

10 In respect of house property, state –

Name Extent Assessment Rating Rates Rent Date of Cost of of land of land No. Assessment payable received Construction Construction per annum

17. Have you, your spouse or any of your children * borrowed any money? If so, state –

Amount Date of such Name and Security Deed No. and Amount Borrowed borrowing address of offered Name of owing at institution or Notary prescribed person from date whom borrowed

I ………………………………………………………………………………do hereby solemnly, sincerely and truly declare that the answers given and the statements made by me herein are true and accurate and that I have made a complete disclosure of all the movable and immovable property belonging to or possessed by me, my spouse, sons and daughters.

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

11 * For the purpose of this Declaration of Assets and Liabilities “Children” shall mean –

(a) children who are unmarried and under 18 years of age : or (b) children who are 18 years of age or over but are dependent on their parent or parents : and includes step children or children who have been adopted under the Adoption of Children Ordinance.

(1) If any of the columns in this form are insufficient for the particulars required, such particulars may be given in a separate schedule or schedules provided that appropriate reference is made to any such accompanying schedules in the return. Such schedules should also be signed.

(2) If in any section of this form there are no items to be recorded, please write ‘NONE” in the appropriate space.