DATA CONSENT FORM AND UNDERTAKING

I/WE hereby knowingly, voluntarily, and fully grant my/our consent on the collection,
recording, organization, storage, modification, retrieval, use, consolidation and such other
processing that may be made by the appropriate authorities of LANDBANK of my personal
information and my dependents’ personal information which includes the following:

(a)Name (Last Name/First Name/Middle Name);

(b)Gender;
(c)Email Address;
(d)Contact Numbers;
(e)Date of Birth;
(f) Current Address;
(g)Clinical Information
(h)other information as classified as “personal data”, “personal information, “sensitive
personal information” under the Data Privacy Act of 2012.

This also grants my/our consent for the authorities of LANDBANK to share/disclose between
and among them or to Zuellig Pharma Corporation or to third parties said data/personal
information for the procurement and administration of vaccines and other logistic services
related to the same.

I also hereby undertake to submit the written authority of my dependents as enumerated in

this form expressly granting me authority as his/her/their agent to sign on his/her/their behalf
the above Data Consent Form and shall submit the same to the authorized personnel of
LANDBANK on or before ___________________.

Name of Dependents:
a. ___________
b. ___________
c. ___________
d. ___________

Witness my signature this ____ day of _________________ 2021, in the _____________.

_____________________________________
Signature over Printed Name