Republic of the Philippines

Province of Aklan

HEALTH DECLARATION CARD

Tourists
Verification ID: 389B8A62-C37E-409F-8FF2-6EB815FC42DC; Date/Time: 2022-04-24 01:59:14; User ID: 1
-- 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

238884d2-da8b-4817-b45b-a431e6ee680f Arrival Date (yyyy-mm-dd): 2022-04-24

Email: ronelborres45@gmail.com Contact No: 09661684512

Passport No/Valid ID Type & No: 110256250551

Name: First Name

Middle Name
Last Name

RONEL TEODOCIO BORRES

Nationality: FILIPINO Sex: M Birthdate (yyyy-mm-dd): 1998-08-05

Flight/Bus Number/Vessel Name: FAI 2819 Seat No: -

Residence Address
Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): 57 DELGADO ST MALIPAYON DELGADO

Municipality/City
Province
Region

ILOILO CITY ILOILO VI

Country(ies) worked, visited and transited in the last 30 days.

NA

H E A L T H   P R O F I L E
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 ?

days?  [  ] Yes   []No

3. Have you been tested positive for COVID-19 using RT-PCR Test ?
  [  ] 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