A'S K HR CONSULTANCY SDN BHD HEALTH DECLARATION FORM NAME; PIUBAMAC Recr BW Aswabex, MALE age: 2+ RICO. AUBM = MA TASE tet: rs = GPE TO appress: tT VTE - 4 Jew Tomer emrmeic Gob 64 Gomveud ve FOS Ere Lompyr crongor (MEDICAL HISTORY EMS ‘REPLY TEMS REPLY Asthma vey Sinus Yes/pio* Diabetes Yes/t Epilepsy Yes/yo~ High Blood Pressure vesiy~ Mental Disorder vesipis™ Tuberculosis Yes“ Colour Blind Yesite" Migraine Yes/Nor Thyroid Yes/tje Heart Disease Yesiyo~ Genetic Disorder Yes/No Have you ever gone through operation? Yes/ ye Have you ever been involved in an accident? Yes/ yr ‘Are you suffering from any in-born disease or physical impairment? Yesyo~ Have you ever been hospitalized? Yes/pio~ Do you have any other illness? Yeso~ ‘Are you currently pregnant (Applicable to female only)? Yes/No (Please provide details here if your reply to the above questions is “Yes”) T hereby declare that the above information is true and to the best of my knowledge and belief. I understand that if I were found to have falsified the above information, the Company may take such action as it deems fit against me including but not limited to the termination of my service without notice. Name: HHukemact Bot WIN Equranoli NRICNO: AMWAY, — AH OEE Date 141 D1 aA