FACULTY OF MEDICINE, UNIVERSITY OF PERADENIYA
Application form for Peradeniya University Gold Medal for Most outstanding student 
graduating from Faculty of Medicine, University of Peradeniya
Students with a GPA > 3.5 or Second Class Upper or above at final MBBS and have passed all examinations in the 1st attempt are eligible to apply for this Gold Medal. Applicants should not have faced or pending disciplinary or legal action while being registered as a student of the university. Please attach copies of certificates/letters as proof 
                                    
Name of Applicant: 	…………………………………………………………………………… 	 
Registration No.: 	…………………………
Home Address: 	……………………………………………………………………………

Mobile No: 		…………………………	Email Address: …………………………

1. Academic Excellence 

Second MBBS Examination		
Results 
	GPA	
Distinctions/Prizes/Medals/Scholarships

Third MBBS Examination		
Results 
	GPA	
Distinctions/Prizes/Medals/Scholarships

Final MBBS Examination		
Results 
	GPA	
Distinctions/Prizes/Medals/Scholarships

2.	Sports 

International level
		
National level
		
University level		
State if you have received university colours 
………………………………………………………………………………………………......................  ………………………………………………………………………………………………………………
………………………………………………………………………………………………………………

3.	Registered Societies & Unions 
State the name of the society/union and the period during which you were in office. 
a)	President 
………………………………………………………………………………………
………………………………………………………………………………………
b)	Secretary 
………………………………………………………………………………………
………………………………………………………………………………………
c)	Treasurer 
………………………………………………………………………………………
………………………………………………………………………………………
d)	Committee member 
………………………………………………………………………………………
………………………………………………………………………………………

4.	Arts, Drama, Music, Literary and Creative work 

International level
		
National level
		
University level		

5. Research 
a) International peer-reviewed publications of full journal articles 
………………………………………………………………………………………
………………………………………………………………………………………
b) National peer-reviewed publications of full journal articles 
………………………………………………………………………………………
………………………………………………………………………………………
c) International abstracts/conference publications 
………………………………………………………………………………………
………………………………………………………………………………………
d) Local abstracts/conference publications 
………………………………………………………………………………………
………………………………………………………………………………………
e) Awards/prices for research 
………………………………………………………………………………………
………………………………………………………………………………………

6. Any achievement that you would like us to consider 
………………………………………………………………………………………
………………………………………………………………………………………

I certify that the above information given by me in this application is accurate and the certificates 
submitted by me are true and correct to my knowledge. 

………..								………………………
Date									Signature of Applicant

(Please attach additional papers if necessary)