SELF DECLARATION
1 son/daughter of
resident of do hereby
declare the following:
1. Thave read the Instructions, guidelines and relevant orders of Govt of India pertaining to
COVID-19 pandemic. I have read information bulletin, instructions and notices related to my
‘examination available at the AKTU, Lucknow website.
2. Thave in the last 14 days (please write Yes/No, wherever applicable):
a, The following flu-like symptoms:
Fever (Yes/No) Cough: (Yes/No)
Sore Throat/Runny Nose (Yes/No) ..
Others-Please Specify:
Breathlessness (Yes/No)
Body Ache (Yes/No)
b. Been in close contact with a confirmed case of Covid-19 (*Close contact” means being,
at less than one-meter distance for more than 15 minutes) (Yes/No)
c. Not been in close contact with a person suffering from COVID-19 and am NOT under
mandatory quarantine (Yes/No) .
4d. Travelled the following cities/ country in the last 14 days prior to arriving at the centre:
city Preity a7 city city
Name of
cities/countr
Date of arrival in centre city
we understand that the health and wellbeing of our community is our first priority; therefore,
the centre reserves the right to deny entry to its premises,
4. Wwe have read the “Examination instructions and COVID-19 guidelines for Final Year
Examination 2019-20” and I/we undertake to abide by the same.
Candidate's signature Pose
Candidates photo (same as ;
in the admit card) Conciate's Mobile No. Parent’s Mobile No.
A3) (Krishna Ohan Yadav) Public Relation Officer Head Post Office Moradabad (Umesha Chandra at Om) S/o Shri Inder Singh, R/o 137/A, Milan Vihar Moradabad
