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Health declaration form singap... Singapore Customs, 55 Newton Road #07-02, Revenue House Singapore 307987 Tel No. 6775 5137 Fax No. 6775 5946 Email: customs NAC customs.gov.SG DECLARATION COVER CERTIFICATION FORM GENERAL INSTRUCTIONS

Health declaration form singap... FGRP039805 THE ASIA LIFE ASSURANCE SOCIETY LIMITED COMPANY REG. NO. 194800055D INCORPORATED IN SINGAPORE ENROLMENT HEALTH DECLARATION FORM Singapore Computer Society s Voluntary Scheme WARNING PURSUANT TO SECTION 25 5 OF THE INSURANCE ACT CAP 142 REVISED EDN 2000 YOU ARE TO DISCLOSE IN THIS ENROLMENT FORM FULLY AND FAITHFULLY ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW OTHERWISE YOU MAY RECEIVE NOTHING FROM THE POLICY. Completed as a condition to the granting of insurance under Group Policy proposed by Name of Organisation SINGAPORE COMPUTER SOCIETY PLANS COVERAGES 1 Living Protector S 50 000 S 100 000 2 Hospital Surgical Protector Plan 1 Plan 2 Plan 3 Plan 4 KINDLY COMPLETE FULLY IN BLOCK LETTERS AND INK. Any alteration in this form must be initialled* PARTICULARS OF LIFE TO BE ASSURED MEMBER Full Name As shown on IC - Underline Surname Sex NRIC / FIN No Member of SCS since dd/mm/yy Occupation - Exact Duties Height cm Weight kg Date of Birth dd/mm/yy DEPENDANTS COVERAGE ONLY FOR HOSPITAL SURGICAL PROTECTOR complete the highlighted portions in item 2 and 3 below. Contact Tel No YES NO. If YES please DEPENDANTS INFORMATION Relationship to Member NRIC / Birth Cert Name Date of Birth DD MM YY Height cm kg Spouse 1st Child 2nd Child 3rd Child HEALTH QUESTIONNAIRE Note Dashes in pen or ditto cannot be accepted as replies. Please indicate Yes or No Have you or has any person named in this form ever had or been told to have or been treated for Yes/No a b c d e f g h i j k l 1st Child 2nd Child 3rd Child Epilepsy fits stroke paralysis weakness of limb prolonged headache unconsciousness nervous breakdown depression or any other nervous / mental disorders or disorders of the brain Diabetes thyroid disorder or any other disorders of the endocrine system Ear discharge nose bleeds impaired sight hearing or speech or any other disorders of the ear eye nose or throat Asthma bloodspitting persistent cough pleurisy tuberculosis or any other Raised cholesterol high or low blood pressure coronary artery disease heart attack rheumatic fever palpitation breathlessness chest discomfort or pain disease of or any other disorders of the heart or the blood vessels Jaundice hepatitis or carrier ulcer hernia chronic indigestion / diarrhoea blood in stools fistula piles or any other disorders of the stomach liver gall bladder intestines or digestive organ Protein blood pus or sugar in urine renal stone or any other disorders of the kidney bladder or genital organs Arthritis slipped disc recurrent back pain gout or any other disorders of the muscle spine limbs or joints or severe injury Sexually transmitted diseases such as gonorrhoea syphilis non-specific urethritis any other venereal disease AIDS or AIDS related condition or infection with any Human Immunodeficiency Virus HIV Cancer tumour cyst growth of any kind please specify cancerous/noncancerous and site of the growth/organ involved Gynaecological disorders such as endometriosis ovarian growth fibroid irregular menstrual bleeding abnormal pap smear results etc Anaemia any other disorders of the blood congenital anomalies physical defects or any other illnesses disorders not mentioned above Signature of Life To Be Assured Signature of Spouse spouse of the Member Date Information on the most current rating is available at www.

Dfds health declaration form DVDs Ferry (Birmingham) HEALTH DECLARATION FORM COVID-19 INTERIM Measure are collecting personal data of visitors to our properties for the purposes of enabling us to carry out contact tracing and

Health declaration form deped... Republic of the Philippines Region VII, Central Visayans Division of Cebu Hudson, La hug, Cebu City SCHOOL STATUS EVALUATION FORM School CD Municipality School Head Item Date : : : : : : Direction

This is an official animal hea... This is an official animal health declaration for all livestock farmers. ANIMAL HEALTH DECLARATION AND FORMAT FORM3. REGISTERED BRAND MARKS ON ESTABLISHMENT Stock Braddock Brand Wherefore answering

Ghana health declaration form GHANA MEDICAL ASSOCIATION Registration form GMA Registration No. First Name. Marital Status (M×S)..................................... Surname Number of Children Other Names. Off. Tel No (s×. Title

Horse health declaration form HORSE HEALTH DECLARATION FORM This form is to accompany your ENTRY Event Name:Date:Full Name Address Suburb Post Voicemail Contact NumberMobileAddress of property of horse Suburb Post Code PIC Number Horses

Pre employment health declarat... PreEmployment Health Declaration Employment with the NSW Department of Education (the Department) is conditional on the applicant being suitable for employment and fully able to perform the inherent requirements

Health declaration form 606571... Our Vision Building a Community of Passionate, Lifelong Learners BSB HEALTH DECLARATION FORM The following form must be completed by all new staff to ensure that you mentally and physically fit to

Health declaration form sample HEALTH DECLARATION Have you made any payment with this application? (Yes / No) and amount if any RM (Inclusive of GST, if any) Certificate No : Important Notice: 1. 2. 3. 4. In accordance with the

Pre employment health declarat... PreEmployment Health Declaration Employment with the NSW Department of Education (the Department) is conditional on the applicant being suitable for employment and fully able to perform the inherent requirements

Seslhd pre employment health d... SESLHD PreEmployment Health Declaration Form Employment with the South Eastern Sydney Local Health District (SESLHD) is conditional on the preferred applicant completing this statutory PreEmployment

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