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Self Declaration Form

- The document is a COVID-19 self-declaration form requiring candidates to declare their health status and recent travel history to ensure the health and safety of the examination community. - It contains details of the candidate Sanjib Bhakta including name, registration number, exam date and center. - The candidate declares that he has not traveled abroad in the past 3 months, been in contact with anyone diagnosed with COVID-19, and is not experiencing symptoms like fever, cough or breathing difficulties. - Candidates who previously tested positive for COVID-19 must produce a medical certificate declaring them fit within 24 hours of the exam.

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Department of power MIS Cell
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326 views1 page

Self Declaration Form

- The document is a COVID-19 self-declaration form requiring candidates to declare their health status and recent travel history to ensure the health and safety of the examination community. - It contains details of the candidate Sanjib Bhakta including name, registration number, exam date and center. - The candidate declares that he has not traveled abroad in the past 3 months, been in contact with anyone diagnosed with COVID-19, and is not experiencing symptoms like fever, cough or breathing difficulties. - Candidates who previously tested positive for COVID-19 must produce a medical certificate declaring them fit within 24 hours of the exam.

Uploaded by

Department of power MIS Cell
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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.
 
SANJIB BHAKTA
Your name: ______________________________________________ 
NISM-201900046709
Registration Number:_____________________________________________ 
Examination Date _______________________________________ 
Examination Time _________________________________________ 
The Calcutta Stock Exchange,, 7, Lyons Range, Ground Floor, Kolkatta, Landmark - Behind
Examination Centre __________________________________________ 
Writer''''s Building and In front of RBI, Kolkata, West Bengal 700001. Tel: +918080806476
40 Years
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

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