Canada Immigration and Visa Services (Principal Immigration Consultant) ‘One Bishops Square London El 6AD United Kingdom EMPLOYMENT HEALTH DECLARATION Fullname Fyad Allie Nationality: \paonesia Passporemumber? C7394. 4} Hereby declare that Ihave had none of the followingsituations in the 14 days immediately preceding the date on this Health Declaration Form: ‘1 Being confirmed or suspected of COVID-19 infection by any medical institution 2. Running a fever at or above 37.3°C or showing respiratory symptoms 3. Coming into contact with confirmed or suspected COVID-19 cases 4. Coming into contact with patients with a fever or respiratory symptoms 5. Staying in a community or hotel reporting confirmed or suspected COVID-19 cases 6.Atleast two persons in my office or family running a fever or showing respiratory symptoms 7. Taking medicine for feveror cold 8 Visiting public spaces like hospitals, theaters, restaurants and leisure facilities or taking part ingroup activities without taking protective measures like wearing a mask. | declare the truthfulness and veracity of the statements above and the COVID-19 negative ‘ertificateI have provided. If any ofthe above-mentioned situations happens to me before leaving for Canada, I shall cancel the trip. {acknowledge and accept the responsibilities under this Declaration pursuant to the relevant Jaws and Tegulations of Canada should I conceal any health condition ‘that might cause the Spread of quarantinable infectious diseases or give rise to serious risks of such spread, Date: (2. /.04/202\ (Day /Month/Year) Ifyou answered ‘yes’ to any of the questi accordancewith the contract ofeat ings reacts ve, you are not allowed to board the aircraft, in ‘Tobe completed by consular officersof the Canada Emb: ae frye ieee : —} Provided by the deci: ae boarding screening by airlines, this health decarsion se valida? Purpose of pre- Seal: Date: ___/__/__(Day/Month/Year) : documents fc i travel and onarrival. You must present this declaea ‘or verification purposes duri asked to do so by airport staff orby the designated airports autho a rity,LETTER OF UNDERTAKINGS & NOTICE ON CANADA LAWS AND REGULATIONS FULL NAME: SEX DATE OF BIRTH, NATIONALITY 2. PASSPORT NO ETgya4gy DATE ISSUED 706 WO 2020 EXPIREDDATE =: Ob _IWOV_2025 POSITION APPLIED : WAIT EQS ‘That, [conformed to and signed on my own free with the Canada Job acceptance offer for three years contract period in Canada through its Indonesia representative PT.SATRIA ABDI PERSADA (PT-SAP), Indonesia, headed by MR SAMUEL.D.SARDJULO Thereby undertake to give my fingerprints and my eye iris pattern images and comply with the laws of Canada, The undersigned, hereby agree to have my fingerprint and iris data (biometrics) captured as part of the application procedure for an entry visa to Canada. I further agree and declare as follows: If granted the visa, Ishall abide by all the laws and regulations of Canada Tam aware that al Illegal Drugs, Terrorism, Pornographic materials or publications that violate thesocial norms of decency and allother publications that are disrespectful of any religious belief o* political orientation are prohibited and shall not be brought into Canadar + Tam also fully aware thatthe crime of smuggling narcotics and other illegal drugs into Canada is punishable by the death penalty. . Thavenever been removed, excluded ot deported from Canada or from: any other state or charged with violation of any law or regulation thereof: + Tagres to depart Canada on or before the expiration date of my visa, Tam well aware that any violation of the laws and regulations of Canada or any engagement in Prohibited activities, such as the activites mentioned herein or in the entry visa documentation, are subject to the penalties described in the "Dealing with Persons on Entry Visas” statute Applicant Signature: Date: u \/oy/ 2.024 Not: If you have a criminal record you may not be allowed to enter Canada, People who Pose a risk to Canada’s security are also not allowed to'come to Canade