PROVINCIAL ANTI-COVID-19 TASK FORCE FORM 4

TRAVEL CLEARANCE
This form is in compliance to Executive Order JL-03 s.2020 issued by Governor Maria Jocelyn Valera Bernos

LGU OF ORIGIN CONTACT NUMBER

FOCAL PERSON OF FOCAL PERSON
RESIDENT'S INFORMATION
PROFILE RESIDENCE IN ABRA
Last Name Street
First Name House Number
Middle Name Barangay
Date of Birth Municipality
Age Cellphone Number
Sex Home Phone Number
Occupation Email Address

Date of travel
Travelling with group? ( ) Yes ( ) No
If yes, other members are required to secure their travel clearance (subject
Destination to certain exceptions)
Est. Time of Departure Details of Transportation to Abra: Model
Est. Time of Arrival Date: Time: Plate No.
Type of Vehicle:___________________
Color:__________________________
To be accomplished by the Municipal Health Officer

QUARANTINE FACILITY FOR RETURNING INDIVIDUAL PURPOSE OF TRAVEL

( ) Medical Services
Municipal Isolation Unit Location: ( ) Government Transaction ( ) Essential Services
Barangay Isolation Unit Location: ( ) International Flight ( ) Others, specify:
Other Location:
I hereby bind myself to the health protocols of the Province of
Abra and do so willingly by affixing my signature herein.

Signature Over Printed Name _____________________ Signature Over Printed Name _____________________
MUNICIPAL HEALTH OFFICER Date REQUESTING INDIVIDUAL Date

JUSTIFICATION FOR TRAVEL

Recommending Approval: APPROVED:

Signature Over Printed Name Signature Over Printed Name

PUNONG BARANGAY MAYOR

To be filled up by Officer-in-Charge for the issuance of Travel Pass

DOCUMENTS PRESENTED

( ) Travel Clearance (Form 4) ( ) Medical Certificate ( ) Valid I.D ( ) OR CR ( ) Proof of Appointment

STP No.
Date of Issuance
Time

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
OFFICER-IN-CHARGE OFFICER-IN-CHARGE OFFICER-IN-CHARGE
RECEIVING PROCESSING RELEASING