Republic of the Philippines

Province of Aklan
HEALTH DECLARATION CARD

Travelers
Verification ID: 96F794C2-AF98-4E0D-A2B5-74654C2C0B52; Date/Time: 2022-06-02 23:36:00; 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
a62841a6-e635-4866-ac53-86a8ca915c04 Arrival Date (yyyy-mm-dd): 2022-06-04
Email: cyneljavier18@gmail.com Contact No: 09196140409
Passpo No/Valid ID Type & No: -
Name: First Name Middle Name Last Name
CYNEL BASA JAVIER
Nationality: - Sex: M Bi hdate (yyyy-mm-dd): 2001-12-10
Flight/Bus Number/Vessel Name: 060102 Seat No: 2
Residence Address Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): STATION 2
Municipality/City Province Region
- - -
Count (ies) worked, visited and transited in the last 30 days.
I STAYED IN SEMINARY
HEALTH PROFILE
1. Have you been sick (cough, di culty breathing, colds, sore throat, fever) in the past 30 days? [ ] Yes [✓
]No
2. Have you been exposed to a con rmed 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 con rm 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. (A icle 171 and 172 of the Revised Penal Code of the Philippines)

Signature