COVID-19 Self Declaration Form 

The Health and safety of our community is of utmost importance and therefore it is mandated
for the appearing candidate to submit the declaration of sound health. Please ensure that the
information you provide below is accurate and complete.
 
Your name: ______________________________________________ 
Registration Number:_____________________________________________ 
Examination Date _______________________________________ 
Examination Time _________________________________________ 
Examination Centre __________________________________________ 
Your age: __________

I declare that:
- I have not traveled abroad in the past three months to the date of the scheduled
examination
- I have not been in contact with anyone being suspected or diagnosed
with COVID-19. 

I also declare that I am not experiencing any of the below health concerns: 
· Fever 
· Cough 
· Shortness of Breath 
· Persistent Pain in the Chest 
- Sore throat
 
Kindly note that in case you were infected with COVID-19 earlier and presently have been
tested negative or cured, then on your scheduled exam date, you are mandated to produce an
original Medical Certificate, in addition to this Self-Declaration Form. The Medical Certificate
shall be issued at least 24 hours prior to the exam date. Further note that you may be disallowed
to enter the test centre to give exam in case you fail to clear the thermal scanner check at the
test centre despite carrying a Medical Certificate declaring you as ‘fit’.

I acknowledge that the information provided by me as above is accurate and to the best of my
knowledge. I hereby assure that the declaration given by me is correct and I have no objection
to NSE Academy for taking any action to ensure healthy and safe conditions at the test center.

Date _______________________ 
 
Signature __________________________ 
 

Confidential