Declaration Form – COVID-19

Required to be submitted by Guest prior to entry to Cebu Mitsumi, Inc.

I, __________________________________________________________________________
(insert full name)
Name of Company: __________________________________________________________________________

hereby certify, represent and warrant as follows:

I HAVE:
a. NOT tested positive or presumptively positive with the Coronavirus or been identified as a potential
carrier of the COVID-19 virus or similar communicable illness (“Coronavirus”):
b. NO manifestations of Covid-19 symptoms for the past 14 days.
c. NO Close Contact with Confirmed Covid-19.
d. NO contact with anyone with manifestations of Covid-19 symptoms.
e. NO Travel to any area confirmed to have Covid-19 cases.
f. To submit myself for Rapid Antibody Diagnostic Test (RDT’s) as required by the Company two (2) days
prior to my arrival and send the soft copy of the said result a day before my visit.

I CAN account for all locations visited over the previous fourteen (14) days and shall provide an exhaustive list
of all locations visited and modes of transportation used below (please attach an additional page if needed):

I AGREE to notify Cebu Mitsumi, Inc. of my fourteen (14) days Daily Temperature and Health Condition prior to
entering the premises of the company;

I WILL, wear mask at all times and will take responsible preventive measures implemented by Cebu Mitsumi,
Inc.;

I WILL consent to having my temperature taken by any representative or agent of Cebu Mitsumi, Inc. prior to
entering, during and while I’m at the premises of the company;

I ACKNOWLEDGE and ACCEPT that this Declaration shall be governed by the Company’s Code of Conduct and
the Data Privacy Act;

I ACKNOWLEDGE and ACCEPT that this Declaration will be considered as my consent to disclose, share, record
and store this Declaration with any relevant authority or service provider for the purposes of ensuring the
safety and security of any and all third parties that may come in contact with me;

I AFFIRM that all the above statement are true and correct. In the event that I will be found not telling the
truth, Cebu Mitsumi, Inc. has the right to file any court or legal action against me.

In signing below, I, knowingly, voluntarily, and freely agree to the terms of this binding Declaration, and in
doing so represent the truthfulness and veracity of the above answers.

_______________________________________ _______________________________
(Signature) (Date)