1 Form HEALTH DECLARATION FORM FOR APPLICANTS Thereby declare that 1am free from the Fllaning dlseases/candiions: TEMS: ‘SELF IF YES, PLEASE | Sra ¥S 80 | Fuberaoss | roy pave scr ests Sondinkon ox ay Hepat 8 oe ie a — ~|Stsaseh/Eonortions fv : fou'sne negoas rg ueabie South ooe mete. i aa ington enon ta 2. Cannabinolds | Prvsretan TTS 3. Amphetamine | EDUCATION maLaysIA 4. Hethomphetamine Soear™ ‘Sxtters uy Tas - fey eet Sey Wreransed SR unvenar Dect + | — eter Congental Fas rer i ‘Cancer | a | ple Poycetic nes | — Ober ess. Tdedare that fwilisubmit myself for compulsory Post-Aival Health Examination a per Malaysian regulations. In the event that 1 should be diagnosed with any condition that deems me UNSUITABLE for studies, I will bear the cost of leaving Malaysia and will aghere to the immigration requirements on the visit pass and ext before the pass expiration, or any deadline given to me whichever is earlier 1 declare that in the event I should be diagnosed with any conelions that does not require my removal from Nalaysia but requires medical treatment and I choose to remain in Malaysia to continue my studies, I wil bear any and all costs relating drecty or indirectly towards the medical management of my medical condition. | confirm that EMGS Panel Clinic/University Health Centre shall not be responsible in any manner ‘or whatsoever, arising out of EMGS Panel Clinic/Universty Health Centre certification of my medical status as sultable to study oF reside in Malaysia despite the medal condition described ‘above. I further undertake to hold EMGS Panel Ginic/University Health Centre harmless from any loss oF labiity arsing from this decision and agree to Indemnity and keep EMGS Panel Clnic/University Health Centre from any oss or ability arising from this decision Date (ame of applicant) 23