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MSF Declaration Form

The document is a declaration form for the Health Care Assistant program, completed by an individual named Nayan Shak. It includes personal information, a series of questions regarding legal and financial background, and a consent statement for the use of this information by the Government of Singapore. The individual confirms that all information provided is true and acknowledges potential legal consequences for false statements.

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199 views2 pages

MSF Declaration Form

The document is a declaration form for the Health Care Assistant program, completed by an individual named Nayan Shak. It includes personal information, a series of questions regarding legal and financial background, and a consent statement for the use of this information by the Government of Singapore. The individual confirms that all information provided is true and acknowledges potential legal consequences for false statements.

Uploaded by

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Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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OFFICIAL (CLOSED) SENSITIVE HIGH

Declaration form

Part I
Name of Programme: Health Care Assistant
Job Designation (Refers to your role in the Organisation, e.g. Social Worker/ Prog Coordinator Volunteer/ Vendor):

Name (according to NRIC): N A Y A N S H A K

Full NRIC/ID No: 2 0 0 5 5 9 1 5 6 4 7 1 2 5 0 7 7 Date of Birth: 2 0 J U N 2 0 0 5

Part II

1. Have you ever been, or are you currently under investigation by the  No
Police or any other law enforcement agency in Singapore or overseas?  Yes

2. Have you been involved as a party to any court proceedings within  No


Singapore or any other court of law outside of Singapore?  Yes

3. Do you have any criminal record in Singapore or overseas (including,  No


but not limited to, records relating to traffic offences)?  Yes

4. Have you been declared financially embarrassed or a bankrupt within  No


the last 10 years?  Yes

5. Have you had any disciplinary proceedings initiated against you  No


by any organisation or professional bodies?  Yes

6. Do you have any substance dependence issues (i.e. dependence on  No


alcohol, drugs, etc.), excluding prescriptions by medical professional?  Yes

If you answered YES to any of the above questions, please provide details below:

9 Nov 2023 1
OFFICIAL (CLOSED) SENSITIVE HIGH
Part III

1 I understand that the above information (“my Personal Information”) will be provided
to the Government of Singapore, as represented by the Ministry of Social and Family
Development (“Government” or “MSF”), for the purpose of assessing my suitability to run,
manage, provide services or volunteer for the Programme (as specified under Part I) .

2 I allow the Government to collect, share and use my Personal Information for the
purposes in Paragraph 1.

3 I declare that the information provided in this form is true and correct and I furnish
the information knowing that I may be liable to criminal prosecution if I have stated any
information which I know to be false or do not believe to be true.

NAYAN SHAK 23/04/2025


Name Signature Date

9 Nov 2023 2

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