<p> 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</p><p>Personal Record and Financial Information </p><p>Name :</p><p>Position :</p><p>Date of appointment to the present position : </p><p>Ministry :</p><p>Salary Scale :</p><p>(A) BIOGRAPHICAL INFORMATION </p><p>1. Name in full :</p><p>2. Address :</p><p>(a) Official : Telephone No :</p><p>(b) Private : Telephone No :</p><p>(c) Mobile No :</p><p>(d) Email :</p><p>3. (a) Date of birth and age :</p><p>(b) Place of Birth : (c) N.I.C. No :</p><p>4. Marital Status :</p><p>5. Citizenship : </p><p>6. Names and ages of children :</p><p>7. (a) Spouse’s post, place of employment and salary, if employed :</p><p>1 (b) Particulars of children’s employment, if any :</p><p>2 8. Education (Include institutions attended and dates) : (Academic)</p><p>Period Grade/Examination Passed Educational Institution From To</p><p>(Professional) Period Name of Course Educational Institution From To</p><p>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)</p><p>Period Post held Institution From To</p><p>10. (a) Last post held and salary drawn :</p><p>3 (b) Write a short description of any progress you have been able to show while serving in a similar position previously:</p><p>11. Memberships : (List all memberships and offices held in professional, fraternal, civic, charitable and other organizations)</p><p>12. Honours and Awards: (List Scholarships, special recognition for outstanding service, etc)</p><p>13. Publications:</p><p>(B) FINANCIAL DATA </p><p>( To be furnished as per annexure)</p><p>(C) FUTURE EMPLOYMENT RELATIONSHIPS </p><p>1. Will you sever all connections with your present employers, business firms, business associations or business organizations if your proposed appointment is confirmed?</p><p>4 2. Has anybody made a commitment to employ your services in any capacity after you leave your proposed assignment?</p><p>5 (D) POTENTIAL CONFLICTS OF INTERESTS </p><p>1. Describe all your financial arrangements, and other continuing dealings with business associates, clients or customers.</p><p>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.</p><p>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.</p><p>4. Explain how you will resolve any potential conflict of interest, including any that may be disclosed by your answers to the above items.</p><p>(E) OTHER</p><p>1. Have you ever been convicted of any criminal violation other than minor traffic offences ?</p><p>2. Have you ever been found guilty of any fundamental rights violations before the Supreme Court ? </p><p>3. Please advise the Committee of any additional information, favourable or unfavourable, which you feel should be considered in connection with your nomination.</p><p>I ……………………………………………………………………… do hereby declare that the answers given and statements made by me herein are true and accurate.</p><p>Date : ………………………… Signature </p><p>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. </p><p>6 ANNEXURE </p><p>DECLARATION OF ASSETS AND LIABILITIES</p><p>Please furnish a statement answering to the requirements in the appended form and giving all details of your wealth as at ………………………………………………….</p><p>1. If married, name of spouse : ………………………………………………………………</p><p>2. If spouse is employed his/her salary and allowances per month : ………………………...</p><p>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. </p><p>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.</p><p>5. Income Tax file number : …………………………………………………………………….</p><p>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 –</p><p>Name and Name of Account Number Date on which Balance at address of Bank Account Holder account was prescribed date opened</p><p>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 –</p><p>Name of Holder of Number of Date and Place of Amount of Investment Certificate Certificates Issue</p><p>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 –</p><p>Name and Date and Rate of interest No. and Date of Name of Notary address of Amount loaned Deed Borrower</p><p>9. Do you, your spouse or any of your children * hold any stocks, shares or debentures ? If so, state - </p><p>Name of Name and Number of Purchase value Date of purchase Shareholder Address of shares held of shares Company</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>15. Do you, your spouse or any of your children* own any motor vehicles, motor boats or other power driven vehicles ? If so, state -</p><p>Type of vehicle Make Registration No. Date of Purchase Price paid</p><p>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 </p><p>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) </p><p>10 In respect of house property, state –</p><p>Name Extent Assessment Rating Rates Rent Date of Cost of of land of land No. Assessment payable received Construction Construction per annum</p><p>17. Have you, your spouse or any of your children * borrowed any money? If so, state –</p><p>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</p><p>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.</p><p>……………………………… ……………………………. Date Signature </p><p>11 * For the purpose of this Declaration of Assets and Liabilities “Children” shall mean –</p><p>(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.</p><p>Notes </p><p>(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.</p><p>(2) If in any section of this form there are no items to be recorded, please write ‘NONE” in the appropriate space.</p><p>12</p>