NIELIT Chandigarh

Birla Farms, Bada Phull, Rupnagar(Ropar)-140001, Punjab

Self Declaration Form – COVID-19

Date of Birth / /
Application (DD/MM/YY)
Form No.
Name of the Mobile
candidate Number
(In Capital
Letters)
Father’s Name Email-id
(In Capital
Letters)
Travelling From Travelling To
(City / Town (City / Town
Name) Name)

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

Other : Please specify

2. Have you or an immediate family member come in close contact with a confirmed case of
Coronavirus in the last 14 days ? (“Close contact” means being at a distance of less than one metre for
more than 15 minutes.)

I have been in close contact with a confirmed case of

Coronavirus in the last 14 days.

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
typing test.

Date : _________________ ______________________________

(Signature of the candidate )

Place : ________________________

NOTE : The health and well being of our community is our priority therefore NIELIT Chandigarh
reserves the right to deny entry to its premises/typing test venue.