SOUTHEAST ASIAN FISHERIES DEVELOPMENT CENTER
AQUACULTURE DEPARTMENT
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Last Name
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First Name
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Middle Name
Date of Birth: _______________
Age: ______ Sex: _____
Address: ___________________
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__________________________
Contact Number:
__________________________
E-mail Address:
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Office Address:
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Occupation: ________________
Nationality: _________________
Address in the Philippines:
(If not a Filipino)
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tats03/2020
Tigbauan, Iloilo
Medical Clinic
Declaration Form
Foreign Countries you have worked, visited, transited or travelled to in
the past 14 days: No: _____
Yes: (Please include the place and date of travel).
________________________________________________________
________________________________________________________
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Cities in the Philippines you have worked, visited, transited or travelled
to in the past 14 days: No: _____
Yes: (Please include the place and date of travel).
________________________________________________________
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Have you been sick of any of the following for the past 14 days?
No Yes
Fever ______________ ______________
Colds ______________ ______________
Cough ______________ ______________
Sore Throat ______________ ______________
Difficulty of breathing ______________ ______________
Diarrhea ______________ ______________
Have you been in close contact with farm animals or exposed to wild
animals in the past 14 days? No: ______
Yes: ____________________________________________________
Declaration:
The information I have given herein is true, correct and complete. I
understand that the failure to answer or any false or wrong information given
may be a ground for filing of a criminal case against me under Articles 171
and 172 of the Revised Penal Code of the Philippines.
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(Signature over printed name)
Date: ____________________