Local Aklanons (not valid for Air/Sea travel)

Republic of the Philippines

Province of Aklan

HEALTH DECLARATION CARD

Local Aklanons (not valid for Air/Sea travel) Provincial Government of Aklan

-- Please read before proceeding --

In compliance with RA 10173 or Data Privacy Act of the Philippines, the personal information you will be providing in this
form shall not be used for other purposes except for COVID-19 contact-tracing activities.

control no.ed0b6a28-b261-4ca6-8117-ca06e5ec8216 Arrival Date (mm-dd-yyyy) : 08-30-2021

Email: - Contact No.: 09091058980

Passport No/Valid ID Type & No : -

First Name Middle Name Last Name
Name PATRICIO MATIONG PAMPLONA
Nationality : - Sex: Male Birthdate (mm-dd-yyyy) : 04-04-1971

Place of Origin: ILOILO CITY Destination/Hotel Name: KALIBO AKLAN

Flight/Bus Number/Vessel Name: NA Seat No.: NA

Street No. and Name of Street ( If applicable, indicate name of barangay)
Residence BARANGAY OLD BUSWANG
Address Municipality/City: Province: Region:
(Philippines) - - -
Country(ies) worked, visited and transited in the last 30 days.

N/A

HEALTH PROFILE
1. Have you been sick (cough, difficulty breathing, colds, sore throat, fever) in the past 30
days?
[ ] Yes [ ] No
2. Have you been exposed to a confirmed case of COVID-19 ? [ ] Yes [ ] No
3. Have you been tested positive for COVID-19 using RT-PCR Test ? [ ] Yes [ ] No

Local Aklanons (not valid for Air/Sea travel)

Upon submitting, I am providing consent to sharing my information for contact tracing
purposes, I confirm that the information I have given is true, correct and complete and that I
understand failure to answer any question may have serious consequences under Philippines
laws. (Article 171 and 172 of the Revised Penal Code of the Philippines)

ed0b6a28-b261-4ca6-8117-ca06e5ec8216
Provincial Government of Aklan Signature

AkQuiRe 2021 ; Maintained by APICTO - 8/3/2021 7:39:46 AM