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,IILI FFt I\1E5 J COVID Declaration Seafarer

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1. Thst I srn a agen'rI ttrLsrstr SFFSH0RE fEEvrlllrlE sERlJttEs

pFt:{-,!Fp{f*€$ fsr its *credited principd
SO|-STAD SFFSHORE CREWING SERVICES PTE. LTU., *rrd refr=tered ves::el
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2, That I shall ',,vitltn$y sr-rbject myself to [:y tonrerned authnritieE rn tne

Fhi!ippines *nd {;r:ut'itriltrrritr,r'rJ ;n,l
cuncerned vEssel's parte of call during my trarel to
andfrnm the latter;

3. fh* t sn inf*rnred and nrade mrare foy pvrnrner* a:thnritieE that I arr pL[ting myself at
pntential ri* nf Exposure to mU D- 15 hy transiting tE {cnunt ry/territnrT J

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4. That I fully un derstand $rh* l h*ve signed and t h* ntr one forced or p rom pted rne to execute thiE
waisEr andthd the fcrepingsider*efits re a|! fa*s

ll',1 WITI{ESS \q/}lEEESn I ha,re herxunto set my l-rand this DEc. o 3 Lo zD

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Mandatory Document Revision date 09,2020
Last revised by JH
App*)ved by
I,&.1. 0f F*g€ :1

COVID-19 is an ernerging strain of coronavirus. lt is a Communicable Disease {can be spread from one person to another}.
Only related to Vessel crew: To maintain a safe a*d healthy environrnent for everyone! we ask you to cornplete the below self-
as$e55*ns'tt arld t* he f*rxrarded t6 yo&r creeiric:g f{} r*rtat*r- lfi$ftsrs are reqaired t* subrclit and reftlr* this farxt electr+*EcaBiy
rior to the vessel,
Narfi*/ Sirtlr Date/ B *ur*b*r: ALFIZEDD E,DIN&PD bErL O q
Vessel: Not\M/ND tNS'tlrLLEP
Company: .rok(I^D DfFfrTD\LE
Cou*fry *f ilrigir:r PH\ L\ PPI N
Destlnation Country; VYt.r
$lgnature:

Date:
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flarrtaet T*tr*phmme #e: tko qL.q4k&olC(/C
Email a\ prc.o\o d rhap O t4ah up . cD h\ . ph
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Do you have any ffu like symptoms: e.g, fuier, runny ncse, cough, sore throat, nausea, vomiting,
1"
or difficulty breathing?
,rBsf
d
2- Have you suffered any significant loss of the sense of sr*ell or taste in the past l4-days? YEsI
d
3. In the past 14 days - have you been in close contact with any person in your home or famiiy
environment who is currently unwell, and suspected or confirmed to be infected with COVID-19?
YEs I N$/
4. Are ycu travellingfroni an area with restrictions on mov€ryrsrt due to a tocal COMD-l9
outbreak? * lf yes please provide details below:
YEst Ny'

5. Do you have any current health concerns that we need to be aware of?
Please specify:
YES / N/

6. I hereby authorize 3d Party COVID Testing companies to communicate my COVID I test

resuits to the norninated Solstad representative.
PCR
r{t *o
7" I confirm I have viewed the COWD infcnnatiox on the fallcnri*gtrrcblink
https://viqeo.com/455492880 ,&*o
if YIS is entered to Questir:ns 1,2, 3, 4 and 5 {urther follow up wi}l be rcquired before joining/enter vessei/office.
- Ior Solstad crew this r#i{i be fsllowed up by your crc\tr coorclinator.
- For all others this will be followed up by the Solstad contact either onshore or onboard the vessel. {Vessel Master
rmaintains full ar:thority tc r*filse boardir:rg if he fe*ts this is rlece$sary to protect the healtti & weilhelng of ai{ crer,*
onboardi
- Access to vessel /office: ln the event that any person has a temperature of >37.8* Celsius entry will not be permitted.
ai0Erts{il'fscleej-The purpase af this inlormntian is tD scr€en pe{sa#nel ot rtsk af c*vtfr-i.g through eit!}€{ 6di$e syfftpta$?s ar rec*ttt
ttit tfirt h;st$ry with peaple Evho sre *r *re suspe$ed be i*fert*ri with C$t/10-J9.
All information disclosed to Solstod is treated in the strictest confidentiality. On boord vessels the dota provided is reviewed solety by the
Vessel Master or O{ficer an Wstch in order to protedt the health & sofety af crew onboard" All forms submitted to Salstad are stared in
resiri.tsd sc{e-rsf/*s +n$**rdj*r c per':'ad cf .?* cl*ps S#cre sac} re*,:rds *re destroyed.
The information disclosed in this document shall not be disclosed in ony circumstances to any other pafty or representative without the
express permission of the individuol completing this form.

F*r the CCIVID labcrato,ry: lf a positive test laboratory forward a mail ts cqyiE!.support@solstad"corn

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