Coronavirus Self-Declaration Form

Due to the on-going and rapidly changing situation with the novel-coronavirus (COVID-19),
we are requiring, all the examinees visiting to STES NBN SSOE Ambegaon, Pune 411041
campus, to fill-out the self-declaration form below.

Full Name:

Email:

Phone number: 1) 2)

Examination Number:

(Mark ‘X’ – for not applicable):

a). Fever (37.5° or higher) Yes No

b). Cough Yes No

c). Breathlessness Yes No

d). Loss of smell and/or taste Yes No

Student’s name of the City, State & Pin Code:

Date of arrival:- Date of departure:-

Coronavirus Self-Declaration Form

By signing this self-declaration form, I confirm that I have not tested positive for Covid-19 in
the last 14 days or been required to be in quarantine during the last 7 days.

The health and wellbeing of our community is our first priority therefore STES reserves the
right to deny entry to the campus.

Signature: _________________________________________________

Date: _____________

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