VG

You will receive an acknowledgement email at the email address you provided. Please check your junk or spam
folder if you cannot find the email.

You may choose to download or print a copy of this acknowledgement.

Providing false health and travel declarations is an offence under Section 64(b) of Singapore's Infectious Diseases
Act. The penalty for providing false or misleading information is a fine of up to S$10,000 and/or imprisonment of
up to 6 months. For subsequent offence(s), the penalty is a fine up to S$20,000 and/or imprisonment of up to 12
months.

You are reminded that it is your responsibility to update and resubmit your declarations prior to your arrival in
Singapore if you had contact with a COVID-19 case, and/or if there is any change in your health status and/or
travel history.

Transaction Date: 12/12/2022 07:08 AM (Singapore Time)

Electronic Health Declaration

Personal Information

NRIC/FIN Date of Birth

*****756K 05/10/1979
Email Address
THAOO51079@GMAIL.COM

Trip Information

Date of Arrival to Singapore

12/12/2022

Have you visited any of the listed countries in Africa or Latin America in the past NO
6 days prior to your arrival in Singapore?

Did you start to have any symptoms in the last 7 days: fever, rash, cough, runny NO
nose, sore throat, loss of sense of smell, or shortness of breath?

Do you currently have fever, cough, shortness of breath, headache, or vomiting NO

AND have visited Africa or the Middle East in the past 14 days prior to your arrival
in Singapore?

Remarks NIL