HEALTH DECLARATION FORM

IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO

FACILITATE NECESSARY PROCEDURES
Name: John Rich R. Alcantara Date: 1-Dec-22
Address: 11 Malinis St., Lawang Bato, Valenzuela CityTemperature: 36.5°
Age: 24 Sex: M Cellphone No.: 9923898055
Status: Single [ ] Employee [ ] Visitor [ ] Applicant [ ✓ ] Contractor
Nature of [ ✓ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________

Position: Test Technician Company: WESTCO

TRAVEL HISTORY:
Have you travelled or did you come from [ ] YES If yes, please indicate country/ies and
anywhere outside of the Philippines during [ ✓ ] NO date/s of travel:
the past 30 days?

Have you travelled or did you come from [ ] YES If yes, please indicate location/s and date/s
anywhere in the Philippines during the past [ ✓ ] NO of travel:
30 days?

Have you been in any other place yesterday [ ] YES If yes, please indicate specific location/s and
after or before your work aside your home? [ ✓ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable
CoVID-19 Patient or with a Barangay Health Worker, Nurse, Doctor or Frontliner who took care
of a confirmed CoVID-19 patient, within an enclosed place
or did you handle specimens extracted from a confirmed CoVID-19 patient during the past 30
days? [ ] YES [ ✓ ] NO

If yes, please indicate specifics:

Are you living with a frontliner? (Doctor, [ ] YES If yes, please indicate name and nature of
Nurse, Provincial/ City/ Brgy. Official, Brgy. [ ✓ ] NO work.
Health Worker, PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third [ ] YES If yes, please indicate name and
Party from UFLEX/UBOPP) who lives within [ ✓ ] NO Department.
your home vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ✓ ] NO
Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ✓ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
[ ] Fever. Indicate here your highest When was this recorded?
temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed
without your prior written consent, and shall be subject to data privacy law and your DP agreement with the Company.
All information provided are TRUE and CORRECT to the best of my knowledge and I understand that I will be subjected
to OSDA on the basis of non-disclosure of critical information in this Health Declaration Form.
Signature: Date: 1-Dec-22

HEALTH DECLARATION FORM

IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO
FACILITATE NECESSARY PROCEDURES
Name: R Jay G. Fran Date: 1-Dec-22
Address: Caloocan City Temperature: 36.5°
Age: 28 Sex: M Cellphone No.: 9927204891
Status: Single [ ] Employee [ ] Visitor [ ] Applicant [ ✓ ] Contractor
Nature of [ ✓ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: Test Engineer Company: WESTCO
TRAVEL HISTORY:
Have you travelled or did you come from [ ] YES If yes, please indicate country/ies and
anywhere outside of the Philippines during [ ✓ ] NO date/s of travel:
the past 30 days?

Have you travelled or did you come from [ ] YES If yes, please indicate location/s and date/s
anywhere in the Philippines during the past [ ✓ ] NO of travel:
30 days?

Have you been in any other place yesterday [ ] YES If yes, please indicate specific location/s and
after or before your work aside your home? [ ✓ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable
CoVID-19 Patient
If yes, please or with
indicate a Barangay Health Worker, Nurse, Doctor or Frontliner who took care
specifics:
Are you living with a frontliner? (Doctor, [ ] YES If yes, please indicate name and nature of
Nurse, Provincial/ City/ Brgy. Official, Brgy. [ ✓ ] NO work.
Health Worker, PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third [ ] YES If yes, please indicate name and
Party from UFLEX/UBOPP) who lives within [ ✓ ] NO Department.
your home vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ✓ ] NO

Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ✓ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
[ ] Fever. Indicate here your highest When was this recorded?
temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed
without your prior written consent, and shall be subject to data privacy law and your DP agreement with the Company.
Signature: Date: 1-Dec-22

HEALTH DECLARATION FORM

IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO
FACILITATE NECESSARY PROCEDURES
Name: Jazzy Villanueva Date: 1-Dec-22
Address: Caloocan City Temperature: 36.1°
Age: 34 Sex: M Cellphone No.: 9368030935
Status: Single [ ] Employee [ ] Visitor [ ] Applicant [ ✓ ] Contractor
Nature of [ ✓ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: Driver Company: WESTCO
TRAVEL HISTORY:
Have you travelled or did you come from [ ] YES If yes, please indicate country/ies and
anywhere outside of the Philippines during [ ✓ ] NO date/s of travel:
the past 30 days?

Have you travelled or did you come from [ ] YES If yes, please indicate location/s and date/s
anywhere in the Philippines during the past [ ✓ ] NO of travel:
30 days?

Have you been in any other place yesterday [ ] YES If yes, please indicate specific location/s and
after or before your work aside your home? [ ✓ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable
CoVID-19 Patient
If yes, please or with
indicate a Barangay Health Worker, Nurse, Doctor or Frontliner who took care
specifics:
Are you living with a frontliner? (Doctor, [ ] YES If yes, please indicate name and nature of
Nurse, Provincial/ City/ Brgy. Official, Brgy. [ ✓ ] NO work.
Health Worker, PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third [ ] YES If yes, please indicate name and
Party from UFLEX/UBOPP) who lives within [ ✓ ] NO Department.
your home vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ✓ ] NO

Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ✓ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
[ ] Fever. Indicate here your highest When was this recorded?
temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed
without your prior written consent, and shall be subject to data privacy law and your DP agreement with the Company.
Signature: Date: 1-Dec-22

HEALTH DECLARATION FORM

IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO
FACILITATE NECESSARY PROCEDURES
Name: Jhonriel Sumadia Date: 1-Dec-22
Address: Quezon City Temperature: 36
Age: 33 Sex: M Cellphone No.: 9923898055
Status: Single [ ] Employee [ ] Visitor [ ] Applicant [ ✓ ] Contractor
Nature of [ ✓ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: Test Technician Company: WESTCO
TRAVEL HISTORY:
Have you travelled or did you come from [ ] YES If yes, please indicate country/ies and
anywhere outside of the Philippines during [ ✓ ] NO date/s of travel:
the past 30 days?

Have you travelled or did you come from [ ] YES If yes, please indicate location/s and date/s
anywhere in the Philippines during the past [ ✓ ] NO of travel:
30 days?

Have you been in any other place yesterday [ ] YES If yes, please indicate specific location/s and
after or before your work aside your home? [ ✓ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable
CoVID-19 Patient
If yes, please or with
indicate a Barangay Health Worker, Nurse, Doctor or Frontliner who took care
specifics:
Are you living with a frontliner? (Doctor, [ ] YES If yes, please indicate name and nature of
Nurse, Provincial/ City/ Brgy. Official, Brgy. [ ✓ ] NO work.
Health Worker, PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third [ ] YES If yes, please indicate name and
Party from UFLEX/UBOPP) who lives within [ ✓ ] NO Department.
your home vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ✓ ] NO

Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ✓ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
[ ] Fever. Indicate here your highest When was this recorded?
temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed
without your prior written consent, and shall be subject to data privacy law and your DP agreement with the Company.
Signature: Date: 1-Dec-22

HEALTH DECLARATION FORM

IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO
FACILITATE NECESSARY PROCEDURES
Name: Henry Festijo Date: 1-Dec-22
Address: Caloocan Temperature: 36.4
Age: 54 Sex: M Cellphone No.: 9476375531
Status: Single [ ] Employee [ ] Visitor [ ] Applicant [ ✓ ] Contractor
Nature of [ ✓ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: Technician Company: WESTCO
TRAVEL HISTORY:
Have you travelled or did you come from [ ] YES If yes, please indicate country/ies and
anywhere outside of the Philippines during [ ✓ ] NO date/s of travel:
the past 30 days?

Have you travelled or did you come from [ ] YES If yes, please indicate location/s and date/s
anywhere in the Philippines during the past [ ✓ ] NO of travel:
30 days?
Have you been in any other place yesterday [ ] YES If yes, please indicate specific location/s and
after or before your work aside your home? [ ✓ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable
CoVID-19 Patient
If yes, please or with
indicate a Barangay Health Worker, Nurse, Doctor or Frontliner who took care
specifics:
Are you living with a frontliner? (Doctor, [ ] YES If yes, please indicate name and nature of
Nurse, Provincial/ City/ Brgy. Official, Brgy. [ ✓ ] NO work.
Health Worker, PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third [ ] YES If yes, please indicate name and
Party from UFLEX/UBOPP) who lives within [ ✓ ] NO Department.
your home vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ✓ ] NO

Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ✓ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
[ ] Fever. Indicate here your highest When was this recorded?
temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed
without your prior written consent, and shall be subject to data privacy law and your DP agreement with the Company.
Signature: Date: 1-Dec-22

HEALTH DECLARATION FORM

IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO
FACILITATE NECESSARY PROCEDURES
Name: Joseph Adrian Mendiola Date: 1-Dec-22
Address: Quezon City Temperature: 36.4
Age: 25 Sex: M Cellphone No.: 9480656713
Status: Single [ ] Employee [ ] Visitor [ ] Applicant [ ✓ ] Contractor
Nature of [ ✓ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: Test Engineer Company: WESTCO
TRAVEL HISTORY:
Have you travelled or did you come from [ ] YES If yes, please indicate country/ies and
anywhere outside of the Philippines during [ ✓ ] NO date/s of travel:
the past 30 days?

Have you travelled or did you come from [ ] YES If yes, please indicate location/s and date/s
anywhere in the Philippines during the past [ ✓ ] NO of travel:
30 days?

Have you been in any other place yesterday [ ] YES If yes, please indicate specific location/s and
after or before your work aside your home? [ ✓ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable
CoVID-19 Patient
If yes, please or with
indicate a Barangay Health Worker, Nurse, Doctor or Frontliner who took care
specifics:
Are you living with a frontliner? (Doctor, [ ] YES If yes, please indicate name and nature of
Nurse, Provincial/ City/ Brgy. Official, Brgy. [ ✓ ] NO work.
Health Worker, PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third [ ] YES If yes, please indicate name and
Party from UFLEX/UBOPP) who lives within [ ✓ ] NO Department.
your home vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ✓ ] NO

Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ✓ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
[ ] Fever. Indicate here your highest When was this recorded?
temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed
without your prior written consent, and shall be subject to data privacy law and your DP agreement with the Company.
Signature: Date: 1-Dec-22

HEALTH DECLARATION FORM

IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO
FACILITATE NECESSARY PROCEDURES
Name: Leo Hermosa Date: 1-Dec-22
Address: Quezon City Temperature: 36.4
Age: 31 Sex: M Cellphone No.: 9480656713
Status: Single [ ] Employee [ ] Visitor [ ] Applicant [ ✓ ] Contractor
Nature of [ ✓ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: Test Engineer Company: WESTCO
TRAVEL HISTORY:
Have you travelled or did you come from [ ] YES If yes, please indicate country/ies and
anywhere outside of the Philippines during [ ✓ ] NO date/s of travel:
the past 30 days?

Have you travelled or did you come from [ ] YES If yes, please indicate location/s and date/s
anywhere in the Philippines during the past [ ✓ ] NO of travel:
30 days?

Have you been in any other place yesterday [ ] YES If yes, please indicate specific location/s and
after or before your work aside your home? [ ✓ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable
CoVID-19 Patient
If yes, please or with
indicate a Barangay Health Worker, Nurse, Doctor or Frontliner who took care
specifics:
Are you living with a frontliner? (Doctor, [ ] YES If yes, please indicate name and nature of
Nurse, Provincial/ City/ Brgy. Official, Brgy. [ ✓ ] NO work.
Health Worker, PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third [ ] YES If yes, please indicate name and
Party from UFLEX/UBOPP) who lives within [ ✓ ] NO Department.
your home vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ✓ ] NO
Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ✓ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
[ ] Fever. Indicate here your highest When was this recorded?
temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed
without your prior written consent, and shall be subject to data privacy law and your DP agreement with the Company.
Signature: Date: 1-Dec-22
 HEALTH DECLARATION FORM
IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO FACILITATE
NECESSARY PROCEDURES
Name: Date:
Address: Temperature:
Age: Sex: Cellphone No.:
Status: [ ] Employee [ ] Visitor [ ] Applicant [ ] Contractor
Nature of [ ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: Company:
TRAVEL HISTORY:
Have you travelled or did you come from anywhere [ ] YES If yes, please indicate country/ies and date/s
outside of the Philippines during the past 30 days? [ ] NO of travel:

Have you travelled or did you come from anywhere in [ ] YES If yes, please indicate location/s and date/s
the Philippines during the past 30 days? [ ] NO of travel:

Have you been in any other place yesterday after or [ ] YES If yes, please indicate specific location/s and
before your work aside your home? [ ] NO date/s:

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable CoVID-19
Patient or with a Barangay Health Worker, Nurse, Doctor or Frontliner who took care of a confirmed
CoVID-19 patient, within an enclosed place or did you handle
specimens extracted from a confirmed CoVID-19 patient during the past 30 days? [ ] YES [ ] NO

If yes, please indicate specifics:

Are you living with a frontliner? (Doctor, Nurse, [ ] YES If yes, please indicate name and nature of
Provincial/ City/ Brgy. Official, Brgy. Health Worker, [ ] NO work.
PNP/AFP, etc.)

Do you have co-URC employee (Direct/Third Party [ ] YES If yes, please indicate name and Department.
from UFLEX/UBOPP) who lives within your home [ ] NO
vicinity?

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ ] NO

Is any one currently under quarantine in the [ ] YES If yes, please indicate start date and reason:
household? [ ] NO

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
When was this recorded?
[ ] Fever. Indicate here your highest temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed without your
prior written consent, and shall be subject to data privacy law and your DP agreement with the Company. All information provided are
TRUE and CORRECT to the best of my knowledge and I understand that I will be subjected to OSDA on the basis of non-disclosure of
critical information in this Health Declaration Form.

Signature: Date:
 HEALTH DECLARATION FORM
IMPORTANT REMINDER: ACCOMPLISH THIS FORM HONESTLY AND COMPLETELY TO FACILITATE
NECESSARY PROCEDURES
Name: Krister Magbuhat Date: 24-Aug-20
Address: Camella Solamente, Soro-soro Karsada, BC Temperature: 36.2
Age: 31 Sex: F Cellphone No.: 9498817543
Status: [ x ] Employee [ ] Visitor [ ] Applicant [ ] Contractor
Nature of [ x ] Work [ ] Meeting [ ] Appointment [ ] Pick-up/Deliver
Visit: [ ] Others,please specify:_________________________________________
Position: HR Supervisor Company: UFLEX
TRAVEL HISTORY:
Have you travelled or did you come from anywhere [ ] YES If yes, please indicate country/ies and date/s
outside of the Philippines during the past 30 days? [ x ] NO of travel:

Have you travelled or did you come from anywhere in [ x ] YES If yes, please indicate location/s and date/s of
the Philippines during the past 30 days? [ ] NO travel: July 23-27 - Malvar, Batangas,

Have you been in any other place yesterday after or [ x ] YES If yes, please indicate specific location/s and
before your work aside your home? [ ] NO date/s:Aug 23- San Pascual

CLOSE CONTACT MONITORING:

Did you work together, travel together, or live together with a confirmed, suspect or probable CoVID-19
Patient or with a Barangay Health Worker, Nurse, Doctor or Frontliner who took care of a confirmed
CoVID-19 patient, within an enclosed place or did you handle
specimens extracted from a confirmed CoVID-19 patient during the past 30 days? [ ] YES [ x ] NO

If yes, please indicate specifics:

Is any one currently ill in the household? [ ] YES If yes,what are the symptoms?
[ x ] NO
Is any one currently under quarantine in the [ x ] YES If yes, please indicate start date and reason:
household? [ ] NO July31, self quarantine. Mom died due to
Lymphoma on July 24. Not swabbed. Burial
was on July 26.

July30, house move in from San Pascual to

Soro-soro. Aug9 registered quarantine in
Brgy.Soro-soro

HEALTH CONDITION:
Please check if you had any of the following at present or during the past 14 days:
[ ] Cough [ ] Shortness of Breath
[ ] Sore Throat [ ] Breathing difficulty
[ ] Runny Nose [ ] Body Pain
[ ] Headache [ ] Dizziness
[ ] Diarrhea [ ] Vomitting
[ ] Loss of sense of smell [ ] Loss of sense of taste
When was this recorded?
[ ] Fever. Indicate here your highest temperature:
Any information submitted herein shall be treated by the Company with utmost confidentiality and shall not be disclosed without your
prior written consent, and shall be subject to data privacy law and your DP agreement with the Company. All information provided are
Signature: Date: 24-Aug-20