I do solemnly declare that:

• I have not been convicted of or had proven against me any offence involving fraud, dishonesty, sexual assault or violence in any State or Territory within or outside of Malaysia and there are no such matters pending
• I have not been found guilty by any regulatory body or court of misconduct or negligence in the conduct of a health service establishment in any State or Territory within or outside of Malaysia and there are no such matters pending
• I have not been the subject of an order by any regulatory body disqualifying me from acting as the proprietor of a health service establishment or an equivalent occupation under the jurisdiction of the regulatory body in any State or Territory within or outside of Malaysia and there are no such matters pending
• I am not an undischarged bankrupt in any State or Territory within or outside of Malaysia and there are no such matters pending
• I undertake and agree to fully indemnify the Government of Malaysia in full from and against all consequences, liabilities, actions, suits, proceedings, damages, costs, claims, demands, expenses, or losses whatsoever which may be taken or made against the Government of Malaysia or incurred or become payable by the Government of Malaysia by reason of or on account of or arising out of endorsing or approving the clinic registration based the above declaration
• I am fully aware that it is a criminal offence to induce the Government of Malaysia to endorse or approve the clinic registration on the basis of a false declaration
• I am also aware that as the penal consequences for a false declaration in respect of the above, I may be punishable under Penal Code [Act 574] read together with Section 3 of the Statutory Declaration Act 1960 [Act 13] or any other applicable law in Malaysia

and I make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of the Statutory Declaration Act 1960 [Act 13]

In case of conflict or discrepancy between the English text and the Bahasa Malaysia translation hereof, the English text shall prevail