TRAVEL DECLARATION FORM

Name :
Organization :
Contact information
:
(email/phone number)

I have traveled to overseas in last 14 days Yes No

If Yes, please mention the country ................................

The details are listed below:

Country and City of Period of Stay

Intended or Recent Travel From To

Example: China, Chaozhou. From 25 Jan to 3 Feb (9 days).

In view of the ongoing Covid 19 situation, Management of PT. Aplikanusa Lintasarta would like to
reiterate that the health and wellbeing of our employee, customers and affiliate partners is of paramount
importance.

We advise all our stakeholders to avoid travelling to affected areas during this period, to remain calm
and vigilant, and to adopt good personal hygiene practices. Should you feel unwell, please seek medical
attention promptly and avoid visiting crowded and public places. This includes the Lintasarta office in
Indonesia. It is important to note that Lintasarta reserves the right to turn away anyone - who is unwell
with flu like symptoms. This also extends to anyone with travel history to overseas in the last 14 days.
This is to further minimize the risk of community spread of the Covid 19 in Indonesia.

You may choose not to fill out this form. If you choose not to fill out this form you will not be permitted
to attend in our office until the Ministry Of Health Republic Of Indonesia declares the health threat and
risk from Covid 19 if negligible

By signing this form, you verify the above information is true.

Signature :
Date :

Acknowledged by Lintasarta :
Date :

Note : - Please enclose your copy passport for the last three destination
- Please bring this form when visit DRC Jatiluhur

 PT.APLIKANUSA LINTASARTA, Indonesia

Travel Decralaration Form V.1