PetroChina International Jabung Ltd. S skkmigas Covid-19 Health Monitoring Statement for Contractor or Visitor Pernyataan Pemantauan Kesehatan Covid-19 untuk Kontraktor atau Visitor ‘This is to certify that : Dengan ini menerangkan bahwa Name Nama Age Umur Company Perusahaan ‘Work Location: Lokasi Kerja ‘Work Duration until Durasi Pekerjaan Handphone number Nomar Loraine ‘Cline formation a the previous 14 aya nformas ns 4 Far selumnpa Suunoamestaec |S | Ya Na | Sok Teragoroken 2 lie Ne Cough Ya ak | Hard bebe = Tk Batu TF byes | | No | Sesak Napas a 5 IN tier Tena Like Tess cota ee Pilek S| ves No | Gejala lain serupa penyakit infers (ete aT te appropriate Dot Ww ie mark [tl png ssw dong wea 7 apport em in nfrinston Isha previous 10 Ga nfs] pomeUseam pomaniong 74 Kar scaumare Tangnal Peapealian vo, | JenisPemeriksan Specimen | Tempet Pomerszann asi "| Type of examination | Date of Collection of | Place of inspection Results Specimen TL RFRER Con [RDF Anigan CooiT9 Tee aed Ta ere ian examination 7D ar od peer 1 declare thatthe above statement is true Saya menyatakan bane pernyataan dias adalah Benar adanya : 2022 Signature Tanda Tangan