TO ,

THE MEDICAL OFFICER

SOUTH ASIAN UNIVERSITY
AKBAR BHAWAN
CHANAKYAPURI
NEW DELHI 110021

Request application for issuing a “ COVID-19 Symptoms Free” Medical Certificate to travel back
home .

I MR/MISS/MRS………………….ANWAR UL HAQ …………………….. request you to issue me a

“Covid-19 Symptoms Free” Medical Certificate as I have to travel to my state/country.

A) My personal information: Name...................................................... ANWAR UL HAQ

Course(MAster/PhD/Year/Semester). Deputy Registrar ‫ ۔‬staff

Date of birth.......................................... 11-NOV-1969

Passport no:........................................... AQ6399693

Mobile number...................................... 8826466966

Permanent address in Home Country.... R 692/, Block 14

Federal B Area

Karachi

Email Address ......................................... anwar@sau.int

One Contact person of family with number................. Seema Anwar

00923092629496

B) Medical information :Cough , cold, fever in the past 3-4 weeks--- No

: history of travel in past 2 months---- No

: Do you have a sore throat----- No

: Cough--- No

:Breathlessness --- No

:Change of taste sensation--- No

 :Change of smell sensation--- No

:Are you being treated for any illness at present. No

:Any morbid illness— BP/DM/ASTHMA/ANY OTHER NO

C) Contact history- Have you come in contact with a “Covid Positive” patient in the past 4-6 weeks.
Yes/no

This is to certify that the above information given by me on date 06-05-2020 is true to

my knowledge and any false information will be liable for action by the appropriate Authorities/

Host Government.

Date: 06-05-2020

Place- SOUTH ASIAN UNIVERSITY

NEW DELHI 110021 Signature of student.
Name in full