Health and Travel Declaration Form

Date Today 12 / 29 / 20
Name JUSTIN JAN B. GULLE
Unit Details Unit 2104, Building 2
Address Unit 2104, Building 2, One Oasis Condominium, Barangay Lapasan, Cagayan de
Oro City, Misamis Oriental
Contact No. 09953227964
Question 1 Have you had travel or a layover in the countries enumerated below?
 China - Yes No X - Date/s of Travel: N/A
 South Korea - Yes No X - Date/s of Travel: N/A
 Iran - Yes No X - Date/s of Travel: N/A
 Italy - Yes No X - Date/s of Travel: N/A
 Japan - Yes No X - Date/s of Travel: N/A
 Hongkong - Yes No X - Date/s of Travel: N/A

Other Countries, please specify:

Country/ies: N/A
Specific Location in said country/ies: N/A
Dates/Duration of Travel: N/A

Date of Arrival to PH: N/A

Have you done a self-quarantine after arriving from said country? Yes No X
If yes, specify dates of self-quarantine: From N/A To N/A

Question 2 Have you had any contact with someone who has travelled to the above-mentioned
countries? Yes No X

If yes, please provide details:

Name: N/A
Date of Contact: N/A
Country Travelled: N/A

Question 3 Have you had any contact with any of the following:
 Person Under Investigation (PUI) Yes No X

 Person Under Monitoring (PUM) Yes No X

 Person with confirmed COVID-19 Yes No X

 If yes, please provide details:
Name: N/A
Date of Contact: N/A
Country Travelled: N/A

Question 4 Do you have any of the following symptoms?

 Fever - Yes No X
 Cough - Yes No X
 Colds - Yes No X
 Shortness of breath - Yes No X
If yes, when did the symptom manifest?

Question 5 Have you taken any paracetamol or medication to lower your body temperature before this
visit?
 Yes ; When (date and time):
 No X

I am voluntarily sharing the above information as part of the Company’s precautionary measures in relation to
the COVID-19. I further affirm that all information stated on this form are true and correct and allow Filinvest
Land Inc. and all subsidiary/affiliate companies to verify any of the information I have declared therein.

I am fully aware that I can be held liable for any misdeclaration or non-declaration made herein or false
information that I have provided herein.

Name: JUSTIN JAN B. GULLE Signature: Date: 12 / 29 / 20