APPLICATION FOR:

Courses: Level 3 CPO Level 3 First Aid Level 4 HECPO*
Packages: 18-Day CPO 21-Day CPO 28-Day CPO*

COURSE DATE APPLYING FOR Date*

Is this your first time applying with UCP THAILAND? No Yes,*If yes, what training program did you take from UCP THAILAND? Type Here* Date of course taken Date*

PRIVACY AND AFFIRMATION STATEMENT: I hereby affirm and declare that the provided information on this application is true and correct and that any fraudulent information stated herein may be considered a sufficient cause for rejection or denial of this information. All information contained in this application is to be used solely for the purpose of UCP THAILAND's requirements for applicants to disclose particular information and is to be used solely for registration purposes only; not to be released for any other purpose to third party such as individuals or other agencies without prior written approval from the applicant.

APPLICANT SIGNATURE: Signature* DATE:Date*

1) Are you suffering from any medical condition (hypertension, diabetes, heart condition) No Yes,* If Yes (Please specify)Type Here
2) Are you currently having any injuries which might aggravate due to strenous activities? No Yes,*If Yes (Please specify)Type Here
3) Have you been diagnosed to have any state of mental disorder? No Yes,* If Yes (Please Specify) Type Here
4) Are you currently in the process of any criminal justice? No Yes,* If Yes (Please specify) Type Here
5) Are you involved in any unlawful organizations or groups which will post a threat to national security? Yes No*

I hereby agree that measures are taken to ensure my safety. UCP THAILAND will not be responsible for any injuries or fatality occurred as a result of my negligience or any underlying medical conditions that I did not declare.

Signature*