This is a legal document and forms part of the basis of your contract. Failure to disclose a material fact, being a fact, which may influence the assessment and acceptance of the application by the Company, could render your contract void. If you are in any doubt as to whether certain facts are material, such facts should be disclosed. Completing a section by a dash, "n/a" or similar mark wil be taken to mean that the answer is nil or none.
I declare that the statements and answers given, including any not filled in myself in my hadwriting are true and complete and I agree that these statements, including any written down at my dictation, together with any statements made or to be made to the Company's medical examiner and signed by me, shall be the basis of my proposed contract of employment.
I understand that if any material fact is withheld or not truly and fairly stated, the contract shall be voided.