[Incorporate Company’s name & Logo]

TRAVEL AND HEALTH DECLARATION

I, __________________________________ (Name), Staff No. ______________________

and NRIC No. _______________________ from (Company/Department) ______________
______________________________ hereby declare that: (please answer Yes or No)

Yes No

i) I did not travel abroad over the past 14 days.

If YES, please state which country(ies):

ii) My family members and I did not attend the Tabligh gathering held in
Sri Petaling between 28 February to 3 March 2020 .

iii) My family members and I have not been in close contact with any
known individual(s) who attended the Tabligh gathering in Sri Petaling
between 28 February to 3 March 2020.

iv) My family members and I have not been in close contact with any
individual(s) suspected or tested positive for COVID-19.

List all events / functions/ gatherings that you have attended in last 14 days:

Event/ Functions/ Gathering Date Venue

I understand and am fully aware that ……………………………………………………………………[state

company] has the discretion to take appropriate action against me if the declaration made
herein in are false or inaccurate.

Signature;

Open
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Name : ____________________________ Date: __________

NRIC : ____________________________

Contact No.: _________________________

Open