Hong Kong Regulations

CIVIL AID SERVICE REGULATION - SCHEDULE 2

FORMS

[section 2]

Form I [section 2(2)]

Declaration of applicant for enrolment declining medical examination

I, ...........................................................................
............................................, do not wish to undergo a medical
examination. I understand that in the event of an application by me for injury
pension or other benefit, or of an application by any person for death
gratuity or dependant pension in respect of me, on the grounds that my injury
or death is due to any injury or illness attributable to my service in the
Service, the application may be prejudiced because of the absence of
information regarding my medical condition prior to enrolment or the
commencement of that service.

..............................................................
.............................................................. Signature of
witness. Signature of Applicant.

..............................................................
.............................................................. Date. Date.

Form II [section 2(3)]

Declaration of member who has not passed the medical examination

I, ...........................................................................
.................................................... , understand that in the
event of an application by me for injury pension or other benefit, or of an
application by any person for death gratuity or dependant pension in respect
of me, on the grounds that my injury or death was due to any injury or illness
attributable to my service in the Service, the application may be prejudiced
because of my medical condition prior to the commencement of that service.

..............................................................
.............................................................. Signature of
witness. Signature of member.

..............................................................
.............................................................. Date. Date.