CITY OF ILAGAN

INTER-AGENCY TASK FORCE

ON COVID 19

TRAVEL PASS
DATE: 4/8/2021 11:16:50
NAME: Almira derraco clemente
HEALTHGUARD NUMBER: HG143758
EMAIL ADDRESS: derracoalmira14@gmail.com
FACEBOOK PROFILE NAME: Almira mhira lozano derraco
PERMANENT ADDRESS (CITY OF ILAGAN): Garcia st.purok7 osmenia ilagan city isabela

CONTACT NO.: 09065281392

DATE OF BIRTH: 11/5/1992
AGE: 28 SEX: Female
TRAVEL DESTINATION/S: D.F.A. tuguegarao city
PURPOSE OF TRAVEL: To renew my passport
PREFERRED DATE OF TRAVEL: 4/20/2021
DATE OF RETURN (If applicable): 4/20/2021
IF REQUEST IS FOR 1 WEEK PASS, ARE YOU TRAVELLING DAILY? No
VEHICLE TO BE USED FOR TRAVEL : Public Transportation
PLATE NUMBER :
NAME OF DRIVER :
ADDRESS OF DRIVER :
DO YOU HAVE TRAVEL COMPANION/S DURING THE TRAVEL?: No
DO YOU HAVE ANY OF THE SYMPTOMS INDICATIVE OF COVID 19: NONE
DO YOU HAVE ANY OF THESE CONDITIONS? (DIABETES, HYPERTENSION, HEART
CONDITION, OTHER/S): NO

ARE YOU OR ANY OF THE TRAVELERS PREGNANT? No

ARE YOU OR ANY OF THE TRAVELERS A PERSON WITH DISABILITY? No
ARE YOU OR ANY OF THE TRAVELERS A SENIOR CITIZEN? No
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TO BE FILLED UP BY THE CITY GOVERNMENT OF ILAGAN REPRESENTATIVE:

ACTION TAKEN:
(✔) ALLOWED TO EXIT CITY OF ILAGAN ON: APRIL 20, 2021 RETURN ON THE
SAME DATE
CONDITION/S: UPON RETURN TO CITY OF ILAGAN, REPORT DIRECTLY TO LGU
TRIAGE AREA/CHECKPOINT FOR ASSESSMENT AND UNDERGO ANTIGEN TEST
SHOULDER BY THE TRAVELER
>UNDERGO MANDATORY STRICT HOME QUARANTINE
>UNDERGO MANDATORY QUARANTINE IF NEEDED (IF ASSESSED WITH SYMPTOMS)

APPROVED BY:

LGU Ilagan Hotline No. 09287181124