STATEMENT OF HEALTH DECLARATION FORM by E22ENyL2

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									CONFIDENTIAL


                                                                           Postgraduate Deanery

                          STATEMENT OF HEALTH DECLARATION FORM



                   candidate for the Induction and Refresher Scheme (IR Scheme)




1     Please indicate below any serious illness(s) or disabilities that you may have:




2     Please complete the following:

      To the best of my knowledge and belief, I am not suffering from any disabilities other
      than those mentioned in (1) above that would interfere with the proper discharge of my
      duties if I were appointed to the post for which I now apply.

        Signed:                                                   Date:



        Name and Address (in capital letters):




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