1/29/22, 6:09 PM Passenger Information Form International Flights

Passenger Information Form

International Flights

This Passenger Information Form is for PAL passengers departing from the Philippines who will
NOT get tested with any of PAL’s Testing Centers (PAL Learning Center or PAL Gate 3).

Please fill out this form as early as 24 hours before your flight.

Each passenger traveling in a group must accomplish the form. The information collected in this
form shall be used in accordance with the law. Please accomplish the form completely and
accurately.

If you are taking your COVID-19 test from a PAL Testing Center please fill-out the PAL Passenger
Health and Declaration Form.

Go to https://bit.ly/PALIntPPHD.

For more information on Departing from the Philippines and quarantine procedures when
arriving in your destination, click this link: https://bit.ly/PALTravelsFromPH

1. LAST NAME

(as it appears in the passport) *

PIMENTEL JR

https://forms.office.com/pages/responsepage.aspx?id=CwHXSIWn90GG3l93kpp6nr8Vyoce92hImmp3WZkt5ZtUNEpQUjFQTlVBRUpBRkFFMDNZUTlKNEhOV… 1/7
1/29/22, 6:09 PM Passenger Information Form International Flights

2. FIRST NAME

(as it appears in the passport)

MARINO

3. MIDDLE NAME

(as it appears in the passport; N/A  if not applicable)

CUSTODIO

4. DATE OF BIRTH *

8/7/1954

5. GENDER: *

Female

Male

6. PASSPORT NUMBER: *

527128350

7. CONTACT NUMBER: 

Please include country code and area code if possible (ex. 639171234567,
63281234567) *
https://forms.office.com/pages/responsepage.aspx?id=CwHXSIWn90GG3l93kpp6nr8Vyoce92hImmp3WZkt5ZtUNEpQUjFQTlVBRUpBRkFFMDNZUTlKNEhOV… 2/7
1/29/22, 6:09 PM Passenger Information Form International Flights

639954589253

8. E-MAIL ADDRESS: *

mpimentel54@gmail.com

9. ADDRESS IN POINT OF ORIGIN:

Please ensure to type the complete address including street, barangay,

municipality or city and zip code.

5206 San Vicente Ferrer St Brgy. 178 Camarin Caloocan City 1423

10. ADDRESS IN POINT OF DESTINATION:

Please ensure to type the complete address in your destination. If a specific

address is not available, please indicate Hotel or P.O. box address (provided by
your organization/company, i.e. Local Manning Agency)

3198 Landess Ave Apt 4 San Jose California 95134

11. FLIGHT NUMBER AND ROUTE: *

PR 0104 / Manila to San Francisco (MNL-SFO) 

12. FLIGHT DATE: *

https://forms.office.com/pages/responsepage.aspx?id=CwHXSIWn90GG3l93kpp6nr8Vyoce92hImmp3WZkt5ZtUNEpQUjFQTlVBRUpBRkFFMDNZUTlKNEhOV… 3/7
1/29/22, 6:09 PM Passenger Information Form International Flights

1/30/2022

VACCINE INFORMATION

13. Have you been vaccinated for COVID-19?

Yes, First Dose Only

Yes, Fully Vaccinated

No

Fully Vaccinated

14. Date First Dose Administered *

5/13/2021

15. Name of First Dose Vaccine *

BioNTech (Pfizer) 

16. Country Where Vaccinated with First Dose *

North America 

17. North America *

United States of America 

https://forms.office.com/pages/responsepage.aspx?id=CwHXSIWn90GG3l93kpp6nr8Vyoce92hImmp3WZkt5ZtUNEpQUjFQTlVBRUpBRkFFMDNZUTlKNEhOV… 4/7
1/29/22, 6:09 PM Passenger Information Form International Flights

18. Date Second Dose Administered *

6/3/2021

19. Name of Second Dose Vaccine *

BioNTech (Pfizer) 

20. Country Where Vaccinated with Second Dose *

North America 

21. North America *

United States of America 

Declaration Release and Waiver

You hereby declare that you are aware of the travel and health check requirements issued for
passengers traveling from the Philippines. 

You are aware and you fully understand that only true and correct information must be provided to PAL
and government agencies/authorities and you understand that you will be held liable for any false or
misleading information. 

For Filipinos traveling on tourist visa or non-essential travel, you here hereby declare that you have
confirmed round trip tickets, and that you have secured adequate travel and health insurance to cover
rebooking and accommodation expenses if stranded, and hospitalization expenses in case of infection. 

You are aware that the country of destination allows travelers and that you may be subject to health
and safety measures imposed by government agencies/authorities to prevent the spread of COVID-19.
That to the best of your knowledge, you are not prohibited from entering thereto based on entry
restrictions or requirements made by appropriate government authorities. 

https://forms.office.com/pages/responsepage.aspx?id=CwHXSIWn90GG3l93kpp6nr8Vyoce92hImmp3WZkt5ZtUNEpQUjFQTlVBRUpBRkFFMDNZUTlKNEhOV… 5/7
1/29/22, 6:09 PM Passenger Information Form International Flights

You understand and acknowledge the potential risks inherent to your travel, including, but not limited
to, flight delay or cancellation, imposition of additional or new border restrictions by your country of
destination, and imposition of additional or new return or entry requirements to the Philippines. You,
therefore, assume full responsibility and accountability on the consequences of these potential risks. 

You further agree that receiving any inoculation (if necessary) is your responsibility and you assume all
consequences for any adverse reactions as a result of taking the inoculation/s or treatment of illness
abroad. You acknowledge and undertake that you have made all preparations necessary to safeguard
your health and that you have complied with all recommended precautions to your health and safety.

You understand and agree that you must comply with all applicable laws, rules, regulations and policies
related to your international travel. 

You also hereby fully forever release and discharge and agree to indemnify and hold free and harmless,
Philippine Airlines, Inc. its officers, directors, employees, agents, insurers, reinsurers, and other parties-
in-interest from any and all known and unknown claims and damages of any nature, including but not
limited to quarantine, and other ensuing medical travel costs that may arise from your restrictions to
enter other countries, and all such other personal or bodily injury and property damages arising from
your voluntary decision to take your flight from the Philippines despite the circumstances as above-
stated, and hereby waive all your rights and claims on account thereof against Philippine Airlines, Inc.,
its officers, directors, employees, agents, insurers, reinsurers and other parties-in-interest.

By clicking NEXT, you agree and make these covenants, release and waivers knowingly and voluntarily.

Important Reminder and Data Privacy

We are collecting and processing your personal data as required by the Philippine Government for
monitoring, contact tracing and preventing the spread of COVID-19. Please ensure that the information
you give is accurate and complete. All information submitted shall be encrypted and strictly used only
in compliance to Philippine laws, guidelines, regulations, and ordinances, in light of the COVID-19
pandemic. By clicking submit and providing the information, you hereby confirm that you: a.) are fully
aware that you can be held criminally liable for any misdeclaration or intentional omission made herein,
pursuant to Republic Act No. 11332 or the "Mandatory Reporting of Notifiable Diseases and Health
Events of Public Concern Act" and other applicable laws and regulations; b.) give your consent to the
collection, use, monitoring, disclosure, or transfer of personal information to applicable local manning
agency, employer or sponsor and government agencies/authorities in accordance with the PAL Data
Privacy Policy for the above-mentioned purpose.

Please take time to read the full copy of the DATA PRIVACY POLICY of Philippine Airlines available at
this link: https://www.philippineairlines.com/en/ph/Home/AboutUs/LegalNotices/Disclaimer to know
more about Philippine Airlines’ (i) purpose for collection and processing (ii) to whom does Philippine
Airlines share your information (iii) security measures in place to protect your information (iv) the rights
of data subjects and (v) how long your information be processed retained. 

You also agree to submit yourself voluntarily, undergo and pay for the COVID-19 Tests to be conducted
by accredited government testing laboratories and accept the terms provided in their consent forms
which are available at their respective testing facilities.

https://forms.office.com/pages/responsepage.aspx?id=CwHXSIWn90GG3l93kpp6nr8Vyoce92hImmp3WZkt5ZtUNEpQUjFQTlVBRUpBRkFFMDNZUTlKNEhOV… 6/7
1/29/22, 6:09 PM Passenger Information Form International Flights

For passengers in charter flights to China, before checking in for your flight, you agree to submit
yourself for an antigen test in the indicated testing facility as required and shouldered by Philippine
Airlines. You also agree that you will not be accepted for carriage should the antigen test yield a
positive result.

This content is created by the owner of the form. The data you submit will be sent to the form owner. Microsoft is not
responsible for the privacy or security practices of its customers, including those of this form owner. Never give out your
password.

Powered by Microsoft Forms |

The owner of this form has not provided a privacy statement as to how they will use your response data. Do not provide
personal or sensitive information.
| Terms of use

https://forms.office.com/pages/responsepage.aspx?id=CwHXSIWn90GG3l93kpp6nr8Vyoce92hImmp3WZkt5ZtUNEpQUjFQTlVBRUpBRkFFMDNZUTlKNEhOV… 7/7