Clone of Clone of Form

District*
Full Name*
National Identity Card No
Name With Initials*
First Appointment date*

MonthDayYear
Current Designation*
Current workplace*
Date of appointment to the current workplace *

MonthDayYear
Date
PHI range*
Date of appointment to Present PHI Range*

MonthDayYear
Date of Birth*

MonthDayYear
Age as at 31.12.2023
Years*
Month*
date*
Telephone No
Permanent Address*

State / Province

Postal / Zip Code
Address of current residence*

State / Province

Postal / Zip Code
Merit number
Relevant year
Current grade*
Date of current grade*

MonthDayYear
Dates on which the relevant efficiency bar examinations have been passed
Grade III

MonthDayYear
Grade II

MonthDayYear
Grade I

MonthDayYear
Details if specially trained
Married/Unmarried*

MarriedUnmarried
Whether Spouse is employed?

YesNo
Occupation of the spouse
Department / Workplace
Number of children not attending school(under 18 years)
Details about children who attend school

Provide details about children who attend school in order

	Name	grade	School
01
02
03
04
05
06

Workplaces served during the entire service period

Mention the workplace in order

	Institute/Workplace	MOH	Service Period (from-to)
01
02
03
04
05
06
07
08
09
10

Stations Selected by the PHI applicant in order of preference (Must Specify 10 stations)
Choice NO 01 (Institute)*
Choice No 01 (Field)*
Choice NO 02 (Institute)*
Choice No 02 (Field)*
Choice NO 03 (Institute)*
Choice No 03 (Field)*
Choice NO 04 (Institute)*
Choice No 04 (Field)*
Choice NO 05 (Institute)*
Choice No 05 (Field)*
Choice NO 06 (Institute)*
Choice No 06 (Field)*
Choice NO 07 (Institute)*
Choice No 07 (Field)*
Choice NO 08 (Institute)*
Choice No 08 (Field)*
Choice NO 09 (Institute)*
Choice No 09 (Field)*
Choice NO 10 (Institute)*
Choice No 10 (Field)*
Stations Selected by the SPHI applicant in order of preference (Must Specify 5 stations)
Choice NO 01 (Institute)*
Choice NO 02 (Institute)*
Choice NO 03 (Institute)*
Choice NO 04 (Institute)*
Choice NO 05 (Institute)*
Do you have any reasons to oppose a transfer from current station?
Have you ever been transferred following a disciplinary procedure?
I hereby confirm that the above information is true and correct
Date*

MonthDayYear
Date
Sign in using the mouse pointer

Clear
To be filled by the head of the institution

I recommend/do not recommend the contents of the application are correct. The applicant can /cannot be released without a successor

date ....................... .......................................

Signature and official seal of the Head of the Institution
IMPORTANT - Please Print Application Before You Submit. After You Submit You cannot print application
My number.................................

Regional Director of Health Services

...............................................

Office of the provincial Director of Health Services, Kandy

The application was checked according to the personal file and I confirm that the information mentioned are correct. I recommend/do not recommend a transfer.

Date ................................... .........................................

Signature and official seal of the Regional Director of Health Services
Should be Empty:

Dates on which the relevant efficiency bar examinations have been passed

Details about children who attend school

Workplaces served during the entire service period

Stations Selected by the PHI applicant in order of preference (Must Specify 10 stations)

Stations Selected by the SPHI applicant in order of preference (Must Specify 5 stations)

IMPORTANT - Please Print Application Before You Submit. After You Submit You cannot print application