Republic of the Philippines

Province of Aklan

HEALTH DECLARATION CARD

Tourists
Verification ID: 4469C26C-30B9-42B2-BBE4-0C222A0838A8; Date/Time: 2022-04-14 15:09:40; 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

1143f1dc-ac1b-4d37-9ee4-ec0b72b3d5cb Arrival Date (yyyy-mm-dd): 2022-04-15

Email: skyymontenegro@gmail.com Contact No: 09054939506

Passport No/Valid ID Type & No: P0625345B

Name: First Name

Middle Name
Last Name

KEVIN SALAPONG MONTENEGRO

Nationality: FILIPINO Sex: M Birthdate (yyyy-mm-dd): 1992-03-02

Flight/Bus Number/Vessel Name: 5j 899 Seat No: -

Residence Address
Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): 23 D RD 12 BRGY BAHAY TORO

Municipality/City
Province
Region

QUEZON CITY MANILA NCR

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
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