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, and/or if there is any change in your health status and/or travel history.

Transaction Date: 11/09/2023 06:22 AM (Singapore Time)

Electronic Health Declaration

Personal Information

NRIC/FIN Date of Birth

*****562K 18/07/1977
Email Address
MAILTOMS@GMAIL.COM

Trip Information

Date of Arrival in Singapore

12/09/2023

Health Declaration

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

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?

Remarks NIL