APPLICATION FOR ISSUANCE OF MEDICAL CLEARANCE

RE: SUPPORT FOR APPLICATION FOR TRAVEL AUTHORITY FOR LOCAL STRANDED INDIVIDUALS
(LSI)
SHOULD BE FILLED UP BY EACH PERSON 18 YEARS OF AGE OR ABOVE PRIOR TO ISSUANCE OF
MEDICAL CLEARANCE REQUIRED UNDER NTF AGAINST COVID 19 ORDER NUMBER 2020-02
NAME OF APPLICANT: SEX NATIONALITY
MALE
FEMALE
ADDRESS OF ORIGIN OF TRAVEL IN MAKATI : APPLICANT’S CONTACT NUMBERS
Cellphone No.:
Landline No.:
Email Address:
ADDRESS OF DESTINATION: DEPARTURE DATE: ARRIVAL DATE:

PURPOSE OF TRAVEL: Mode of Travel:

Land Air Sea
L
NAME/S OF MINOR/S TRAVELLING WITH Travel Details (For land travel, state vehicle
APPLICANT (when applicable) Plate No.; For sea travel state name of shipping lines
and Voyage Number; for air travel provide Airlines
Name/s Relation to and Flt Number)
Applicant

I HEREBY DECLARE UNDER OATH THAT ALL OF THE ABOVE INFORMATION IS CORRECT AND THAT
NEITHER I, OR MY COMPANIONS IDENTIFIED ABOVE, HAVE BEEN IN CONTACT WITH A CONFIRMED
COVID-19 POSITIVE PERSON, NOR HAVE ANYONE OF US BEEN FOUND COVID-19 POSITIVE, OR
SUSPECT, OR PROBABLE, OR PUM, OR PUI, FOLLOWING DOH GUIDELINES.

I FURHTER DECLARE THAT I TOGETHER WITH MY COMPANIONS HAVE UNDERGONE VOLUNTARY

QUARANTINE FOR 14 DAYS IMMEDIATELY PRIOR TO THE SUBMISSION OF THIS APPLICATION.

I AM FULLY AWARE THAT THE ABOVE DECLARATION WILL BE USED AS BASIS FOR THE ISSUANCE OF
THE REQUIRED TRAVEL PASS/ AUTHORITY PURSUANT TO NTF AGAINST COVID 19 ORDER NUMBER
2020-02 AND THAT ANY UNTRUTHFUL STATEMENT SHALL MAKE ME LIABLE PURSUANT TO EXISTING
LAWS, RULES AND REGULATIONS.

____________________________
(APPLICANT’S PRINTED NAME & SIGNATURE)