Republic of the Philippines

Province of Aklan
HEALTH DECLARATION CARD

Tourists
Verification ID: 23C39E6C-8022-4B36-9CAB-692C4C957BF5; Date/Time: 2022-05-01 16:08:39; 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

fa58fbbd-e5ad-4c77-b6d5-4980027704f5 Arrival Date (yyyy-mm-dd): 2022-05-03

Email: aborotallanp@gmail.com Contact No: 09777429575

Passport No/Valid ID Type & No: OFFICE ID PPA01852002

Name: First Name Middle Name Last Name

ALLAN PABLICO ABOROT
Nationality: FILIPINO Sex: M Birthdate (yyyy-mm-dd): 1977-10-06

Flight/Bus Number/Vessel Name: grand xing Seat No: -

Residence Address Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): 166 A VILLAROSA ROAD BARANGAY BANCAO BANCAO

Municipality/City Province Region

PUERTO PALAWAN IV-B
PRINCESA CITY
Country(ies) worked, visited and transited in the last 30 days.

PHILIPPINES

HEALTH PROFILE
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