*Please read instructions on page 04 and in Circular No.03 (01)/ 2009 before completing.

* If a family member or a resident of an applicant is sitting this examination, he/she can apply for an Assistant Examiner post only.

01. Subject No. & subject applied for marking :

02. Town No. and town you wish to do marking : (Town closest to place of work or permanent residence. Please see the list of towns on page 04.)

(a) First choice : (b) Second choice :

03. (a) Name with initials : Rev./Mr./Ms. .................................................................................................................

(b) Names denoted by initials : .......................................................................................................................................

(c) Postal address : .......................................................................................................................................

(d) E-mail address : .......................................................................................................................................

(e) Gender : ........................ (f) National identity card No. :

04. Present working (a) District : (b) Education zone :

(c) Permanent residential district and address : ...........................................................................

........................................................................... 05. (a) Official address : ................................................................................................................................................................ (b) Telephone Nos. : Official Home Mobile

06. (a) Date of birth:

(b) Age as at 31.12.2017:

07. Date of appointment as a teacher:

08. (a) Present post : ....................................................... (b) Service & grade/ class : ............................................. (c) Date of appointment to above post :

09. (a) Date of appointment as a trained/ NCOE/ graduate teacher: (Strike off words inapplicable.)

(b) Period of service after the above appointment : Years

10. Period of service as a holder of Diploma/ Post Graduate Diploma in Education or similar qualification: Years

11. (a) Academic and professional qualifications: (If this section is incomplete, application will be rejected.)

G.C.E. (O/L) Examination - 2017Application for Selection of Marking Examiners

Incomplete applications will be rejected.* O/L2017

Last Served

ldr®hd, m%%fhdackh i`oyd

Marks Code No.FOR OFFICE USE

Y YY YD D

Y Y

M M

D D

Y YY Y

Academic/ Professional/ Other Qualifications

CourseFollowed

Year Completed

Subjects Passed (Compulsory to State Subjects)

Class Received (If any)

Name of University/ Training College/ Institution

Training relevant to subject applied

Degree relevant to subject applied

Any other qualifications

To be filled by the examiner. Year Town

Code No.

(b) If you have participated in national level activities related to the subject, state in brief. (Contribution to prepare textbooks, teacher's guides, prototype question papers, evaluation reports or publication of subject-related books.) Please attach copies of relevant letters. ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

09/OL/2017

Y YY YD D M M

Y YY YD D

M M

The closing date of Applications is 05 th July 2017.

For English medium examiners only.

M M

M M Y YY YD D

12. Fill in 12(a), (b), (c) according to your duties :(a) For teachers and lecturers : (i)

(ii) No. of periods you teach the subject applied (iii) Results of school at G.C.E. (O/L) - 2016 of the subject in G.C.E. (O/L) classes per week: applied for marking : Subject No. : Subject : Grade 10 Grade 11 (First shy) Grade 11 (Second shy)

Total No. of periods

(iv) No. of Assessments conducted by you for Grade 10 and 11 under the SBA program for the relevant subject in the year 2017: In Term I of 2017 In Term II of 2017

Assessment types you have chosen for above: ........................................................ ...................................................... ....................................................... ........................................................ ...................................................... ....................................................... ........................................................ ...................................................... .......................................................

I hereby certify that the personal time table, statistics about results and information regarding SBA furnished above are correct according to the relevant documents.

................................................. (Official frank ) ....................................................... Name of Deputy Principal Signature & Date

(b) For In-service advisers : (i) Date of appointment to ISA service:

(ii) Subject/ subject field : ................................................................................................................................................

(iii) Zone : ............................................ Division : .........................................

(iv) Your duties related to this subject : (If there are any special projects conducted by you in the year 2017, please mention them.) ..............................................................................................................................................

(c) For other officers working in education field :

(i) Relevant subject field : Date of appointment : (ii) Work you are engaged in relation to the subject applied for marking and to the G.C.E. (O/L) syllabus : .................. .................................................................................................................................................................................. I hereby certify that the above information is true.

............................................................................. Date : .................................. Signature of Zonal/ Divisional Director of Education/ Head of Institution (Official frank is compulsory.)

Grade

TimeMonday Tuesday Wednesday Thursday Friday

Subject Grade Subject Grade Subject Grade Subject Grade Subject Grade

02

Complete personal time table approved for year 2017 (with Subjects & Grades)

You are thoroughly advised not to submit incorrect time tables. Disciplinary action will be taken against the teachers and heads of institutions who submit false time tables.

Y YY YD D M M

Y YY YD D M M

Overall result of school

Result of students you taught

No. sat

No. passed Pass percentage

No.of periods

Conducted Planned

13. Experience regarding evaluation: (a) G.C.E. (O/L) Examination

(i) Experience as an Assistant Examiner : Years

(ii) Experience as an Assistant Examiner of the subject applied : Years

(iii) Experience as a Chief Examiner of the subject applied : Years

(iv) Year you last attended marking of the subject applied : Code No. :

(b) G.C.E. (A/L) Examination

(i) Experience as an Assistant Examiner : Years (ii) Experience as a Chief/ Additional Chief Examiner : Years

(iii) Year of last attended marking : Code No. :

(c) (i) If you were appointed as an Assistant/Chief Examiner in 2016 and could not attend duties, indicate the reasons. .................................................................................................................................................................................... (ii) If you have participated in marking earlier and did not participate in recent years, indicate the reasons. ................................................................................................................................................................................... (iii) Would you like to accept a Chief Examiner post this year, if given? Yes No

(d) (i) Experience as an EMF : Years

(ii) If you served as an EMF in 2016, your code No. :

G.C.E. (A/L) G.C.E. (O/L) Grade 5 Scholarship

14. Are you, a family member or a resident of your house expected to sit this examination this year ? Yes No

If yes, from which district is it ? ............................................................ (See Paragraph 1.5 on page 04.)

15. (a) Is any disciplinary inquiry against you in progress? Yes No

(b) (i) Are you debarred from examination duties ? Yes No

(ii) If yes, give details ......................................................................................................................................................

16. Declaration of applicant :

Date : ........................................... ........................................... Signature of Applicant17. Recommendation of the certifying officer : (a) State your recommendation clearly regarding the selection of this applicant for marking of the above examination. .................................................................................................................................................................................. (b) I hereby certify that the information contained in Sections 01 to 12 and in Section 15 is correct and that this applicant is suitable to serve as a marking examiner, and I agree to release him/ her if selected. ....................................... Signature of Principal/ Head of Institution Name : .................................................................................. Address : ..............................................................................

(Official frank is compulsory.)

Date : ..........................................

03

To be certified by the Principal for a teacher, by the Zonal/ Divisional Director of Education for an ISA and by the Head of Institution for any other officer.

I hereby declare that the information given above is true and accurate and that I am not debarred from marking at present and I am aware that I will be subjected to disciplinary action if found to have submitted false information and mislead the department. If I am selected as a marking examiner, I agree to safeguard the dignity of the institution where the marking center is established and abide by its rules and regulations, and follow the provisions of the Public Examinations Act as well as the instructions given by the Commissioner General of Examinations and abide by the code of ethics for evaluation staff.

Tick ( Ã ) the relevant box.(If these boxes are not filled application will be rejected.)

(Tick ( Ã ) the relevant box.)

01. Instructions to complete the application: 1.1 Instructions of Circular No. 03 (01)/ 2009 dated 01.03.2011 should be followed. 1.2 Teachers and officers working under the Ministry of Education and fulfill the following requirements can apply. (a) Having studied the subject applied for the teacher training (ordinary or special)/ NCOE training/ Degree and have received a proper and permanent appointment. (b) Teaching the subject in G.C.E. (O/L) (Grade 10, 11) classes if a teacher or engaged in duties related to G.C.E. (O/L) syllabus, if any other officer. (If you are a Principal, please do not apply.) 1.3 When filling Section 11, it is compulsory to note down qualifications relevant to the subject. Failure to state subjects will result in rejection of the application. 1.4 When filling Section No.14 & 15, clearly indicate 'Yes' or 'No' with a ' Ã ' in the relevant box. If this section is not completed properly your application will be rejected. * If there's a disciplinary inquiry in progress against you or you are debarred from marking, you cannot submit an application form. 1.5 A family member means your spouse, children, grand children or your or spouse's siblings and their children. 1.6 A separate application should be submitted, if you are applying for an additional subject.

1.7 It is expected to establish Evaluation Centers in the following towns:

N.B. Evaluation Centers will not be established in towns where sufficient number of applications is not received. Therefore your second choice also should be mentioned. 1.8 Appointment will be given to the town closest to the private or official address. If there are no evaluation panels of the subject applied in the closest center or if there are no vacancies, you will be directed to another closer evaluation center. 1.9 Fill this form (except Section 17) and handover to the Principal / Head of your institution.

02. Certifying officer: Certification should be done by the Principal for a teacher, by the Zonal / Divisional Director of Education for an In-service Advisor and Head of Institution for any other officer.

03. Instructions to certifying officer:

3.1 Examine whether the information provided by the applicant is correct.

3.2 Certifying that the information is correct at the relevant place on page 03 is compulsory.

3.3 It is the responsibility of certifying officer to indicate recommendation on Section 17 and authenticate with signature and official frank.

3.3 This is a confidential report. Keep copies of applications after certification and send along with a schedule to reach the following address on or before July 05, 2017. Indicate "Application for Marking Examiners - OL 2017" on top left corner of the envelope.

01. Colombo02. Maharahama03. Homagama04. Piliyandala05. Moratuwa06. Hanwella07. Avissawella08. Horana09. Panadura10. Kalutara11. Mathugama12. Negombo

13. Gampaha 14. Nittambuwa15. Ratnapura16. Pelmadulla17. Embilipitiya18. Balangoda19. Bandarawela20. Badulla21. Welimada22. Mahiyangana23. Ambalangoda24. Elpitiya

25. Galle26. Akuressa27. Matara28. Tangalle29. Hambantota30. Kurunegala31. Nikaweratiya32. Kuliyapitiya33. Chilaw34. Kekirawa35. Anuradhapura36. Polonnaruwa

37. Trincomalee38. Kegalle39. Peradeniya40. Gampola41. Kandy42. Matale43. Theldeniya44. Nuwara Eliya45. Hatton46. Monaragala47. Ampara48. Kalmunai

04

Commissioner General of ExaminationsEvaluation (School Exams) Branch

Department of Examinations, Sri LankaP. O. Box. 1503

Colombo

This application form is published in the Department's website too. (www.doenets.lk)

49. Akkareipattu50. Batticaloa51. Vavuniya52. Mannar53. Jaffna54. Nelliadi55. Kilinochchi56. Puttalam57. Dambulla58. Wellawaya

If the subject applied is different from subjects offered for training or degree, indicate qualifications forproficiency of the subjects applied. ex : G.C.E. (A/L), Daham School Examination, Bauddha Dharmacharaya.