Republic of the Philippines

Province of Aklan

HEALTH DECLARATION CARD

Local Aklanons

-- 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. b1f51a97-7267-46f6-a278-18e64b50123f
First Name Middle Name Last Name
Name MAY AN GRACE NERBAR PAGOT
Vehicle/Plate/Bus Seat
nabas ambulance mv0798 passebger
Number No.
Mobile/Contact Destinatio
No:
09124805674 NABAS AKLAN
n
Address (Street/Barangay, Municipality,
Province) POBLACION NABAS AKLAN
Place/Province worked, visited and transited in the last 7 days.
NABAS AKLAN

Have you been sick in the past 7 days? [ ] Yes [ ] No

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) Signature of Passenger/Crew
Notation by the QMO:

Signed:

Name and signature of QMO-on-Duty

Date and Time

Aklan Border Control Management App 2020 ; Maintained by APICTO - 12/6/2020 3:43:34 AM