ANNEXURE-4

Self Declaration Form – COVID-19

Date of Birth
Application (DD/MM/YY)
Name.
Aadhar Mobile
Number Number

1. Do you have any of the following Flu like symptoms (Please tick anyone option) :

Description Yes No

Fever ( 38 degree or higher )

Cough

Breathlessness

Sore Throat

Are you from containment Zone

Have you travelled during last 14 days

Have you been in contact with people being infected or

Diagnosed with COVID 19

Other : Please specify

I hereby declare that all the information mentioned above is true to the best of my knowledge and will
immediately inform to COVID-19 Central/State Govt. Authority, if any symptoms arise during or after
the visit.

Place :
(Signature of the candidate )