2023 GLOBAL KOREA SCHOLARSHIP

Undergraduate Degree Program

Application Checklist

☒ Embassy Track (공관전형) ☐ University Track (대학전형)

Name of Institution Receiving Application (공관/대학명): ___________________________________________________

Name of Applicant(성명) : (Family, Given, Middle) CHAURASIA, SRISHTI

Country of Citizenship(국가) : INDIA

Checklist (Submission of Documents) Please check (√) in the appropriate box.

Type No. Application Documents Note Check

1 (form 1) Application Form
2 (form 2) Personal Statement
Documents to 3 (form 3) Study Plan
Required
complete 4 (form 4) ONE letter of Recommendation
5 (form 5) GKS Applicant Agreement
6 (form 6) Personal Medical Assessment
7 Proof of citizenship (applicant and parents) and proof of family relationship
8 High School Graduation Certificate (or certificate of expected graduation) Required

Required 9 Academic transcript of high school curriculum

certificates Graduation certicate (or certificate of expected graduation) of associate
10
degree program
*Submit with
11 Academic transcript of associate degree Required for
apostille/consular-
confirmation relevant
12 Proof of Overseas Korean Document
applicants
13 Proof of Korean Citizenship Renunciation Document
14 Proof of Korean War Veteran's Descendant
15 Score report of valid TOPIK (original) or English Proficiency Test (copy) Optional

Other 16 Copy of awards and other certificates, etc. (copy) Optional

documents Required for
17 Applicant's Passport (copy) relevant
applicants

FORM 1. 2023 Global Korea Scholarship Application

Items marked in the red box are required for all applicants.

Click the box(☐) to check or uncheck.

1. Application Track 지원 전형
☒ Embassy Track 공관전형 ☐ University Track 대학전형
2. Type of Application 지원 프로그램
[Embassy Track] ☒ General 일반 ☐ Overseas Koreans 재외동포
[University Track] ☐ UIC 산학협력과정 ☐ Regional University 지방대 ☐ Associate Degree 전문학사
3. Degree Program to Apply 지원 학위 과정
☒ Bachelor’s Degree 학사 ☐ Associate Degree 전문학사
4. Desired Field of Study (Division) 희망계열 (You can select multiple fields) * Please refer to the “University Information” file

☐ Liberal Arts 인문 ☐ Social Science 사회 ☒ Natural Science 자연과학

☒ Arts and Sports 예체능 ☐ Education 교육 ☐ Medicine 의학
☐ Engineering 공학 ☐ Artificial Intelligence (AI) 인공지능(AI)

Please complete the form below. It must be typed in English ONLY. Delete the examples when typing your own information.
5. Information of the Applicant 지원자 정보
Family Name 성 CHAURASIA
Full Name Given Name 이름 SRISHTI
성명 Photo
Middle Name 중간 이름
Size: 3cm x 4 cm
*Please write your full name as indicated on your passport or official documents
증명사진
Date of Birth (YYYY-MM-DD)
Gender 성별 ☐ Male ☒ Female
생년월일 2002-07-12
Country of Citizenship 국적 INDIA

Korean Citizenship Applicant’s Parent(s) ☐ Yes ☒ No

Applicant ☐ Yes ☒ No
한국국적 여부 (if any one of your parents has Korean Citizenship, check ‘YES’)

Address
230 B/2 SULTAN PUR BHAWA, PRAYAGRAJ, UTTARPRADESH, INDIA (211003)
Contact Information Phone (start with the country code)
지원자 본인 연락처 +919956119300
*Must be applicant’s
E-mail
srishti93009300@gmail.com

6. Language Abilities 어학 능력

☐1 ☐2 ☐3 ☐4 ☐5 ☐6 급 English Proficiency Test ☐ TOEIC e.g., 850

TOPIK Level
Scores
한국어능력시험 성적
Test Held/Test Date (회차/ 영어공인시험 성적 ☐ TOEFL
 시험일)
e.g., 78th, 2021-10-16 ☐ IELTS

7. Level of Education 학력 정보
High School Program (Required for all applicants)

High School Name 학교명

TAGORE PUBLIC SCHOOL
Location (Country) 소재국 INDIA
High School Period of Attendance
고등학교 재학 기간 2019-2021( 11th ~ 12th )
Date of graduation Date indicated in your graduation certificate
졸업일 (2021-07-30)
Date of expected graduation Date indicated in your certificate of expected graduation (required for relevant applicants)
졸업예정일 (YYYY-MM-DD)

Associate Degree (Required for Applicants who have Associate Degree)

University Name 학교명 SADANLAL SAVALDAS KHANNA GIRLS DEGREE

Location (Country) 소재국 PRAYAGRAJ, UTTAR PRADESH, INDIA

University/Institute Major 전공 DIPLOMA IN FASHION DESIGN (ONE YEAR)

전문학사 기관
Date of graduation Date indicated in your graduation certificate
졸업일 (YYYY-MM-DD)
Degree awarded date Date indicated in your diploma. It may or may not be the same as your graduation date.
학위 수여일 (YYYY-MM-DD)
Date of expected graduation Date indicated in your certificate of expected graduation (required for relevant applicants)
졸업예정일 (YYYY-MM-DD)

Have you ever earned a bachelor’s degree in the past? ☐ Yes ☒ No

8. Information on Academic Transcript / Grades 성적 정보

CGPA Score Percentile

최종평균평점 백분율 환산 점수
Cumulative GPA (CGPA) CGPA indicated on your original transcript If your transcript does not have score percentile,
refer to Appendix A. GPA Conversion Table to
of Previous program* 85.4/100 convert your CGPA into 100 points scale
직전 학위
Converted CGPA (in 4.0, 4.3, 4.5, 5.0, or 100 scale only)
전체평균평점
85.4/100 85.4/100
※ MUST be confirmed by the school/university ☒ Yes ☐ No
* If you have (or are expected to receive) an associate degree, please fill in your grades achieved from the associate degree program
GPA indicated on your original academic transcript 성적표 상 표기된 학기별/학년별 평점
* If needed, you may modify columns
Year 1st year 2nd year 3rd year 4th year

Semester
1 2 1 2 1 2 1 2
/Term
 Grades
or Rank 60.1/100 / 87.8/100 / 85.4/100 / / /

※ If your academic transcript only indicates CGPA and does not provide GPA per semester, then you may leave this table empty.

9. Choice of University and Department 지원대학 및 학과

Other (i.e., major)
Field of Study (Division)
University 대학 Department 학과 (optional)
계열 기타(세부전공 등)
Daegu University Entertainment Division of Fashion
Choice 1
&Sports (Fashion Design)
☒ Seoul National University Textiles,
Embassy Choice 2 Natural science Merchandising and
Track Fashion Design
Ewha Women’s University Entertainment &
Choice 3 Fashion Design
sports
choose universities among Type A or B
☐ University Track

※ Attention! Please refer to “University Information” file posted with the application guidelines. If necessary, copy and paste.
 Embassy Track applicants can choose up to THREE different universities in any order of preference. However, Choice 1 must be
from Type B universities.
 University Track applicants must choose ONE university.
 Field of Study (Division) and Department should match the information provided in the “University Information” file.

10. Previous Visits to Korea or Currently Residing in Korea (if any) 한국 방문 혹은 체류 정보(해당자만 기재)

Period Purpose of Stay City/Region Affiliated Organization (if any) Visa Type
방문/체류 기간 방문/체류 목적 도시/지역 방문/체류 기관(해당자만) 비자 종류
e.g., Korean language
e.g., 2020.July~August e.g., Seoul e.g., GKS University e.g., D-4
study

※ Please put your visa type especially when you are currently residing in Korea.

11. Previously Received Scholarship from Korean Government or Institutions (if any) 한국 장학금 수혜사실(해당자만)

Period Name of the Scholarship Sponsor

수혜 기간 장학금명 지원 기관
e.g., GKS Non-degree program for foreign exchange
e.g., NIIED
students

THE ANSWERS I HAVE GIVEN ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. IF MY

ANSWERS CONTAIN ANY KIND OF FALSEHOOD, I WILL TAKE ANY LEGAL RESPONSIBILITY.
Date (2022-10-2) Applicant’s Full Name CHAURASIA SRISHTI Signature

FORM 2. PERSONAL STATEMENT

Instructions: Please type in Korean or in English. The essay must be single spaced within TWO pages, with the font Times New Roman/
바탕체/돋움체, size 11. (11 points) The essay should include the following items. Please remove the instructions after reading it.

 My childhood is very different from my same aged children cause other kids love to collect keychains,
bracelets, coins but mine is, I like to collect the pictures cutting of celebrities and models from the
newspaper and magazines wearing fashionable clothes and paste those pictures in my personal diary.
From the age of 12 year my love for drawings arts and crafts started. As I grew up I become more
interested toward Fashion Designing and I have always been mesmerized by hearing the name fashion
designer. I started watching fashion shows on television where Designer showcasing their designs of
clothing and accessories. Since childhood, I have enjoyed Designing my dresses, my friends and Family
Relatives said that when you became a designer please make one Dress for me once I am getting married.
It makes me really happy and they praise me on my decision to pursuing career in fashion designing.
When there is a family occasions or party I help my friends and family members to manage there outfits.
They enjoyed my service of to getting ready from me.

 Fashion to me is a road of self – discovery. It gives my creative streak a sense of direction and allow me
to express myself. Being artistic in nature, I find extreme pleasure in merging my art education with
fashion, whether it is in terms of prints, patterns or illustrations, and designing clothing out of it. I have
always found pleasure in adding that extra bit of glitter to an otherwise mundane scenario.

 According to my interest in fashion designing since my childhood. It captivated me to choose my career

in fashion design and textile for my undergraduate degree in South Korea. I choose to study in South
Korea for my bachelor’s because Korean culture suits me and I got really hit by the wide fashion industry
in South Korea it is the fashion capital of Asia. If Europe is the fashion capital of France, Britain, America
and Italy. South Korea is the fashion powerhouse of Asia. Studying abroad in a world class University
through this Global Korea Scholarship program in undergraduate degree. It will put me directly in the
supervision of highly specialized professors with their lectures to work and practice directly in the
garment factory. The South Korea’s education system made me more competitive in my subject as
compared to my country’s education system. Korea is quite famous for the Hallyu along with the fashion
sense and style of Idols. For these reasons I choose Korea as a Destination to study as well as to pursue
my passion for Fashion.

 Ever, since I was a little girl, I studied in Allahabad public school till my High school This is my first
school where I made many memories and won certificates, trophies, and medals in the competitions like,
essays writing, Art and craft, calligraphy, poem writing and sports, etc. In my first school my name
spelling is Shristi till class 9th grade then I changed my name Spelling to Srishti. After my High School, I
moved to Tagore public school in 2019 for my senior secondary education for two year. In this school I
got chance to study fashion studies as my optional subject with humanities to fulfill my Curiosity and also
my English speaking is get improved while studying in this school. Before studying in this school I only
speaks Hindi and Sanskrit. I scored 85.4% in senior secondary and scored 92/100 Second highest mark in
my fashion studies subject in my senior secondary school. I got a medal and a certificate from the Hindi
daily newspaper name Dainik Jagran. However studying fashion studies in school this only peaked my
curiosity even more. As I Now understood the designing of Fashion principles, pattern construction,
Human Figure, etc. I am able to create new design. During school I have made many projects related to
my fashion studies subject in school like client project and the fashion portfolio. So to further continue
this interest I am currently pursuing in a one year Diploma course in fashion design at Sadanlal Savaldas
Khanna girls degree College Which is affiliated with University of Allahabad.

 My parents were very supportive they motivates me and teaches me that, Education is the only weapon
with which you can change the world. In lockdown of COVID 19 pandemic, I take an Few online
workshop of like Sustainable Fashion course of one weak by the University of Petroleum and Energy
Studies, where I made my first own design denim which I named as Frill Jeans by using my mother’s old
 Saree. I also participated in the “outcome based education during and post COVID 19”, it is done virtually
from the prestigious University of United Group of Institutions in my city.

 I Think Global Korea Scholarship offers one of the best environments for international students and along
with the university in South Korea provides the plenty of opportunity to international students to
participate in clubs, and academic societies, along with career and recreational events. I am confident that
the disciplinary education and culture acceptance that I’m getting in South Korea will greatly benefit me
in the future as both a citizen of the world.

Date (2022-10-02) Applicant’s Full Name CHAURASIA SRISHTI Signature

FORM 3. STUDY PLAN

Language Study o Study plans to improve Korean/English language ability required for taking a degree
Plan course before and after you come to Korea.

1-) Before coming to South Korea:-

 I am always improving my English and Korean speaking skills. From last year I started giving English
speaking tuition classes to the school kids of class 3rd and up to 6th. This help me a lot to Keep up my English
speaking. Along with that, I have self- taught myself Hangul and basic Korean by using ‘hellotalk’ app, preply
website and Some YouTube channel of teaching Basic Korean. I will use those resources habitually and make
myself able to communicate decently with Korean around me on daily basis and while going to the super markets,
shops, etc.

2-) After coming to South Korea :-

a) December 2022 – June 2023.

•My Korean language course started for one year as I land in South Korea. For 1 st six month, I will go through
my Korean language Syllabus briefly and capture the word and memorize them which will helpful for my studies in
future.
•Enrich my vocabulary by using different methods like flashcard, Crossword, puzzles, quiz, etc.
•I join the language exchange clubs at my university where I am studying to improve my Korean language and
English speaking skills.
• I will complete the daily work given by my language teacher.
• I will try my best to obtain TOPIK level 3 by may 2023.

b) June 2023 – Decembe2023.

• Reading books and novel is my Side time. I read almost everyday for 1 to 2 hour.
• Reading newspaper and Korean novels and book make me a to learn more easily.
• I start watching Korean news, T.V. shows and Dramas to learn more useful Korean expressions which I used
in basis and able to help local people in Korea.
• By the end of my language year I would advance my Korean Language speaking skills in the language year and
want to become a fluent Korean speaker.
•For my undergraduate major course I need to get the TOPIK level 5 or 6 as per the university guidelines to continue
my education in South Korea. And planning to get TOPIK level 5 by the September.

‘Learning new language at that country will expand the persons learning capabilities and enhance the experience of
having new culture and traditions with new people '. First I checked the curriculum of each universities in advanced
about the TOPIK levels and then I created this plan.

Goal of study &

o Goal of study and detailed study plan
Study Plan

Happiness is the most essential thing in life. If a person knows what makes them happy they can easily achieve their
goals in life. My happiness lies in the field of Fashion Design, Textile and merchandizing. For me Fashion is the
form of personal development which make the persons statement in Lifestyle. I want to expertise my knowledge in
fashion designing and Textiles. My interest was always looking at the trend and not just keeping it to myself but
standing out to make other people think wow.

As I enter in the academic year of obtaining bachelor degree in South Korea as a Global Korean scholarship scholar.
I will sincerely participate in the classroom activities and try to pass all the academic test with a GPA more than 3.5
on the scale of 4.0. I will spent most of my time in libraries and university labs to make my work more attractive and
pleasant. I would like to share our respective country’s traditional costume design and cultures with other
international GKS scholar and my Korean mates and desire to learn Korean culture and traditions. In the University,
I am able to learn the Division of fiber in fashion, History of western costume, Socio – psychological of clothing,
history of Korean costume, human body illustration, pattern making, clothing and health, etc. which expand my
limited knowledge in fashion design and textile in South Korea.
This is my goal one, In my surrounding, I have seen many people that they are not comfortable to carry or not
confident enough to wear fashionable clothes in society’s. I want to teach them on how to build their confidence for
wearing fashionable things and how to enhance their personal development. Fashion is one thing that catches the
viewer’s Eye’s by wearing cloth, accessories to make your body look beautiful. By doing fashion we can easily able
to know what’s the buyers and persons Personal choice in fashion. I want to enhance the fashion vision of my home
country.

My second Goal is, I want to learn sustainable fashion development like textile printing, dyeing techniques and want
Future Plan
o Future plan in Korea or another country after finishing GKS program
after Study

After completing the bachelor’s degree in South Korea through this Global Korean scholarship program. After
my graduation, I am hoping to stay in South Korea and continue to walk this path in fashion design, textile and
Merchandising. Upon Ultimate successful completion of bachelor degree journey in South Korea. I would love to
gain more experiences in fashion brands so that I could prepare myself to launch my own brand ultimately. I love
the process of making clothes with all my heart.

In today’s world, everyone is moving or tend towards the fast fashion by buying branded or luxurious items
without even thinking that how it can effect the environment. My aim of studying fashion design is to get
sustainable fashion or eco friendly fashions, I want to achieve a carbon-neutral fashion industry to built on equality,
animal welfare, social justice and I want to give booster on handmade small business of clothing and thrifting
sustainable fashion which is being unnoticed situated in small city or town. This is I want improve and able to create
awareness about, that there is no planet B. I want to represent both the country South Korea (the country where I
gain knowledge in my field) and India where I grown-up and dreamed to become a environment friendly fashion
designer) in the 2030s sustainable development goal. I want to make both the countries proud and became an
inspiration of the upcoming young generations. That every person should know, How you can save the mother earth
by obtaining Sustainable Fashion and by following this we can save our planets creatures and our nature in time.

Fashion is about dreaming and making other people dream by Donatella Versace, this line motivates me a lot and
making me to change the way people’s Perceived fashion industry also.

I think Global Korea Scholarship offers one of the best environments for international students and along with the
university in South Korea provides the plenty of opportunity to international students to participate in clubs, and
academic societies, along with career and recreational events.

Instructions: Please type in Korean or in English. The essay must be single spaced within THREE pages, with the font Times New Roman/
바탕체/돋움체, size 11. (11 points) Please remove the instructions after reading it.

Date (2022-10-02) Applicant’s Full Name CHAURASIA SRISHTI Signature

 FORM 4. RECOMMENDATION LETTER
Instructions: Please fill in your name and other required information below and deliver (or email) this form to the person who will write the
recommendation letter. Request your referee to seal the letter of recommendation in an official envelope and sign across the back flap.
Recommendation letters that are not dated, signed, or sealed will not be accepted.

Name of Applicant: (Family Name) (Given Name)

Country of Citizenship:

Desired Degree Program: ☐ Bachelor’s Degree ☐ Associate Degree

Intended Major:

To be completed by the referee:

Your frank and candid evaluation of the applicant will be highly appreciated in the selection of Global Korea Scholarship
awardees and the admissions to a Korean university. We greatly appreciate your time and effort.

*You may use your own recommendation letter template and attach your letter to this form. We hope to glean the
following information of the applicant from your recommendation letter:

- How long have you known the applicant and in what relationship?
- What are applicant’s capabilities, strengths, and weaknesses? (in regards to academic achievement, passion and interest for intended
major, future academic potential, integrity, responsibility, independence, creativity, adaptability, communication skills, and others)
- Please comment on the applicant’s performance record, potential, or personal qualities which you believe would be helpful in
considering the applicant’s application for the proposed degree program.

Recommender’s Name

Recommender’s Signature Date

Position or Title: School (Institution):

Address:

(zip-code: )

Email: Tel:

! Instruction for the recommender: After completing the recommendation letter, please add date and your signature at the
bottom. Recommendation letters that are not signed and dated will not be considered valid. Please attach this form and your
recommendation letter sealed in an envelope (sign across the back flap) and deliver the sealed envelope to the applicant.

!! For the recommenders of Embassy Track Applicants: Please printout or make three additional photocopies of the letter you
wrote and sign all copies (1 original and 3 photocopied letters) respectively. Please enclose all 4 letters and this form altogether
in an official envelope and sign across the back flap.
 FORM 5. GKS APPLICANT AGREEMENT

As an applicant for 2023 Global Korea Scholarship for Undergraduate degree program, I
agree to abide by the following;

(1) The information I have provided in this application forms are true and accurate and all
documents I submitted to the National Institute for International Education (hereafter NIIED)
are genuine. ☒
(2) I understand that all the documents submitted to NIIED for GKS will not be returned regardless
of the final outcome of the selection process. ☒
(3) I will abide by all the Korean laws and ordinances. ☒
(4) I will respect and uphold the values of the Korean culture and society. ☒
(5) I will fulfill my responsibilities as a GKS scholar to the best of my abilities. ☒
(6) I will not participate in any form of political activities (such as organizing or joining a political
party, attending political meetings, publishing articles and declarations, and organizing or
participating in political demonstrations). ☒
(7) I will maintain financial integrity at a personal level. ☒
(8) I accept NIIED’s decision concerning the degree program and the Korean language program.
☒
(9) I understand that once I am selected as a GKS scholar. I am not permitted to change the
university, either for the Korean language program. ☒
(10) I will abide by the academic regulations and requirements of NIIED, Korean language
institution, and university. ☒
(11) I understand that if I have any dependents that will accompany me to Korea, I am responsible
for all matters concerning those dependents such as visa issuance and that NIIED will not
provide any extra expenses or support regarding my dependents. ☒
(12) I give permission to NIIED, the Ministry of Education of Korea, the Ministry of
Foreign Affairs of Korea, the Ministry of Justice of Korea, and affiliated institutions to use the
contact information provided in my application for the purpose of visa issuance,
communication, conducting surveys, and sharing information as needed. ☒
(13) I hereby authorize NIIED to verify the information disclosed in this application form
and the documents required by GKS as well as to collect any other information deemed
necessary by GKS to determine my suitability as an applicant from any institution, organization
or individual issuing said information and/or documentation. This includes but is not limited to
contacting recommenders or previous employers. ☒
(14) I hereby understand that all information provided to NIIED will be stored in secured
servers where access will be limited to GKS team and its affiliates. I understand that all
reasonable efforts will be made to protect confidential and sensitive information. By signing
below and submitting my application, I agree to these terms. ☒
(15) I understand that failure to uphold any of the above statements may be grounds for
termination of my scholarship offer. ☒

(continued in the next page)

「National Institute for International Education (NIIED)」 intents to collect and use your
personal information including disclosure to third parties for the GKS selection, based on the
 「Personal Information Protection Act」 and its provisions. We will use the collected data only for
its intended purpose and inform the user for an agreement whenever the purpose of information
collection is changed. Please provide us whether you agree or not on the terms of personal data
collection and usage after referring to the information below.

Agreement on Collection and Use of Personal Data

NIIED collects and uses the applicants’ Personal Information; and is able to provide such information for a third party in
accordance with NIIED policy and regulations.
-
Personal Information Collected: name, date of birth, sex, nationality, contact information, TOPIK score,
career and educational record, university information applied, and language proficiency
- Purpose: Selecting GKS Scholar
- Retention Period: more than 5 years
① If you do not approve our collection and use of your personal information, you have the right to refuse to the use of
personal information mentioned above. However, due to your refusal, your application may be excluded in the selection
procedure.

✘ Agree Disagree
Agreement on Collection and Use of Sensitive Information
① NIIED collects and uses the participants’ Sensitive Information; and is able to provide such information for a third party
in accordance with NIIED’s policy and regulations.
- Sensitive Information Collected : Medical information
- Purpose: Selecting GKS Scholar
- Retention Period : At least 5 years for hard copy / 20 years for soft copy
② If you do not approve our collection and use of your personal information, you have the right to refuse to the use of
personal information mentioned above. However, due to your refusal, your application may be excluded in the selection
procedure.

✘ Agree Disagree

I confirm that I read all of the above conditions. I also understand that the violation of any one of
the above might result in warning or cancellation of the scholarship.

Date (2022-10-02) Applicant’s Full Name CHAURASIA SRISHTI Signature

FORM 6. PERSONAL MEDICAL ASSESSMENT

Attention! This form is just a personal medical assessment and applicants do not need to get a comprehensive medical examination at this stage.
However, all applicants who pass the 2 nd round of selection must receive comprehensive medical checkup and submit an Official Medical
Examination issued by a medical doctor or a licensed hospital. (The Official Medical Examination form will be posted in the GKS Notice board
along with the announcement of successful candidates of 2 nd round of selection) After arriving in Korea, all GKS scholars will be subject to a
medical examination (including TBPE drug test) administered by NIIED in accordance with the requirements of the Korea Immigration Service.
If the results show that the applicant is unfit to study and live overseas, he or she may be disqualified from the scholarship.

Gender ☐ Male ☒ Female HEIGHT 151cm WEIGHT 55kg

QUESTION YES NO IF YES, PLEASE EXPLAIN
Have you ever had an infectious disease that posed a
NO
risk to public health? (e.g. tuberculosis)
Do you have allergies? NO
Do you have hyper tension? NO
Do you have diabetes? NO
Do you have any type of Hepatitis? NO
Have you ever suffered from or been treated for
depression, anxiety, or any other mental or mood
NO
disorder? (If you have received treatment, please
explain and attach an official medical report.)
Have you ever been addicted to alcohol? NO
Have you ever abused any narcotic, stimulant,
hallucinogen or other substance, either legally or NO
illegally?
Have you been hospitalized in the last two (2) years? NO
Have you had any serious injury, ailment or sickness
NO
in the last five (5) years?
Do you have any visual or hearing impairment? NO
Do you have any physical disabilities? NO
Do you have any cognitive/mental disabilities? NO
Are you taking any prescribed medication? NO
Are you on a special diet? NO
Are you pregnant? NO

Date (2022-10-02) Applicant’s Full Name CHAURASIA SRISHTI Signature