EXTERNAL DECLARATION FORM

About this Form

In view of the prevailing COVID-19 (Corona Virus) threat, as preventive and anticipatory
action, you are required to fill out this declaration form and pass the safety measures
contained herein, before conducting a physical meeting with any of our colleagues within or
outside our office. Same treatment is applied towards our staff. Unless otherwise obliged by
the prevailing laws and regulations in Indonesia, we will keep confidential any information
submitted by you in this form.

The Undersigned:

Name : _______________________________________________
Company Name : _______________________________________________
Nationality : _______________________________________________
Passport or ID No. : _______________________________________________
Mobile Number : _______________________________________________

Health Condition

Please answer below questions:

No. Statement Yes No

1. I am aware of the prevailing Covid-19 threat, and confirm
that neither I nor my family have been suspected or
confirmed as infected with this virus.

2. I am not experiencing any Covid-19 symptoms, such as

fever, cough, runny nose, sore throat and trouble breathing.

3. I experience some of the above symptoms, but confirmed as

Covid-19 negative - Please attach evidence.

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Travel History

No. Question Yes No

1. I or my family have not been travelling to or from out of
Indonesia for the past two weeks.

2. If the above statement is not true, please indicate below the

country of transit or destination, and your staying period
there:

No. Country From To

1.
2.
3.

3. To the best of my knowledge, neither I nor my family have

met with any person with suspected or confirmed COVID-
19 status within the past two weeks.

My current body temperature is below 37o Celcius, as notified by your building

security when I enter this building: ___________

Confirmation

I hereby declare that I have answered all the questions correctly.

Signature : _______________________________
Date (DD/MM/YY) : _______________________________

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