|Medical History - Please give details below of any illnesses, operations or accidents:
I hereby declare that, to my best knowledge and belief, the above statement and particulars are true and complete. I also authorise you to make any inquiry you consider necessary in connection with this application. I undertake to furnish any alterations to the above particulars should I apply for further credit at any time in the future. I am aware that, should this application be refused, no reason need be given.
I understand that any misrepresentation of factual information requested on this application form maybe a cause for removal from the Chicken Cottage systems.
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