RCBC Plaza

HEALTH DECLARATION FORM

COVID-19

The health and safety of our tenants and employees remains as our top priority here in RCBC Plaza. It is obligatory upon all of us to
remain vigilant in preventing the spread of coronavirus and reducing the potential risk of exposure of everyone within the confines of
RCBC Plaza. Please answer this form to help us take the necessary precautionary measures to protect you and our community.

Temperature Reading
to be written by Security on Duty

Full Name
Last Name First Name Middle Name Sex Age

Contact Details
Company Name Contact Number City of Residence

Supplier
Contractor
Purpose of Visit Service Provider Tenant to be visited Floor/Tower
Other

Yes No
1 Are you experiencing: Sore throat * *
Body pains * *
Headache * *
Fever for the past few days * *
2 In the last 14 days, have you worked together or stayed in the same close * *
environment of a confirmed COVID-19 case?
3 In the last 14 days, have you had any contact with anyone with fever, * *
cough, cold, and sore throat?
4 In the last 14 days, have you travelled outside of the Philippines? * *
5 Have you travelled to any other city aside from your home? Specify if yes: * *
___________________

Certification and Data Privacy Consent

I certify that the information I have provided is true, correct and complete. I understand that I am required under RA No. 11469
(Bayanihan to Heal as One Act) to provide truthful information, and that my failure to answer or any false/wrong information given
may be a ground for the filing of appropriate cases against me under the law. I hereby give my full consent to RCBC Realty Corporation
(the "Company") to collect, record, and process information, whether personal, sensitive, or privileged, pertaining to myself for the
purpose of drafting and implementing policies related to the prevention and/or containment of COVID-19. In this connection, I
acknowledge that I have read, understoon and/or have been fully informed of terms and conditions pertaining to the data privacy
practices of the Company as reflected in the Company's Data Privacy Policy at http://www.rcbcplaza.com.ph/data-privacy-notice and I
hereby express my full conformity thereto.

Name and Signature Date

RCBC Realty Corporation, its agents, assigns or authorized representative/s reserves the right to refuse entry into the RCBC Plaza
premises any person who fails or refuses to accomplish and submit this form, and who it reasonably deems may pose a risk to other
people.