COVID - 19 DECLARATION FORM

All passengers travelling on any Malindo Air flight must complete and present a digital copy of this form at the check-in counter. Passengers who fail to do
so, may be denied boarding. All passengers must sit on the assigned seats stated on your boarding passes. It is also a mandatory requirement to have
your face mask on at all times, before, during and after your flight and you are reminded to strictly adhere to all safety and security
announcements or requests from the crew onboard.

PART A - GENERAL

1. Full name : SARDi AHADIYANAh

2. Flight No/Date : OD0348/22 Mar 2021 3. PNR No.(Booking Ref) : LCLWFO

4. NRIC/ Passport No : AU504962 5. Nationality : Indonesian

6. Home Address : 42 LAKE FIELDS, LINGARAN PINGGIRAN TASIK 1, TAMAN TASIK PINGGIRAN,

7. Address at Destination : Jakarta

8. Mobile : 60122056697 9. Email : thomaswong2601@yahoo.coM

PART B - HEALTH

1. Have you had any of the following symptoms over the past 14 days? Please tick ( ✔ ) if yes

( ) Fever ( ) Cough ( ) Difficulty in breathing ( ) Sore throat ( ) No Symptoms

2. Have you been in close contact with persons suspected to have COVID-19?

( ) Yes ( ✔ ) No

If the answer is yes to either of the questions above, please report to the nearest registered clinic to get a: COVID-19 Declaration letter.

Definition of close contact:

• Health care associated exposure, including providing direct care for COVID-19 patients, working with health care workers infected with COVID-19,
visiting patients or staying in the same close environment/household of a COVID-19 patient.
• Traveling together with COVID-19 patient in any kind of conveyance

By completing and submitting this COVID-19 DECLARATION FORM, I the undersigned, hereby declare that the information stated above details are true
and correct. I also agree to hold harmless and indemnify and keep indemnified MALINDO AIRWAYS SDN BHD’s Directors, Officers, Employees,
Associates, Agents and Representatives against any and all claims made by me, on my behalf, by any relative, kith or kin, by any third party or by my estate in
respect thereof.

Signature: ……………………………………… Date : ………………………………………