timestamp : 5/10/2022 10:24:51

appointment date : 5/10/2022 STATUS: CLEAR! | APPROVED | 5/10/2022 10:24:51

appointment time : 11:00:00 AM
contact person : ACCOUNTS PAYABLES - Silverio, Richelle Layco

SUPPLIER INFORMATION
Name Cortez, Yodibert Health Status CLEAR!
Company Supercool Airconditioning Center / Capricorn AirconditioningAge
Inc 33
Employee Position Company Messenger Sex Male
Visitor Category SUPPLIER Email Address capricornaircon@yahoo.com
Appointment Category |collection Contact Number 09176787874
PREVENTION AND CONTROL OF COVID-19

1. Do You Currently Have A Fever Reaching 37.5 Degree Celsius?

No

2. Do You Have A Fever For The Past Few Days?

No

3. Do You Have A Body Pain?

No

4. Do You Have A Headache?

No

4. Have You Worked Together Or Stayed Together In The Same Close Envronent Of A Confirmed Covid 19 Case?
No

5. Have You Had Any Contact With Anyone With Fever, Cough, Colds And Sore Throat In The Past 2 Weeks?
No

6. Have You Travelled Outside Of The Philippines In The Past 14 Days?

No

7. Have You Traveled To Any Area In NCR Aside From Your Home?
No

5. Have You Travelled To Places / Areas That Are Classified As High Risk Zone? No

SUPPLIER CONFORME
Declaration and Data Privacy Consent Form

I hereby certify that the above-mentioned information are true, correct, complete, and based on my personal
knowledge. I understand that failure to answer the questions or giving of false information or answer may be
penalized in accordance with law.

Further, I am aware that giving false information or withholding the required information may jeopardize
myself, my family, my community and my workplace.

I voluntarily and freely consent to the collection and sharing of the above information only in relation to the
company's COVID-19 internal protocols and can only be used in the latter's purpose or objective.

SUPPLIER NAME SUPPLIER SIGNATURE

Cortez, Yodibert APPROVED | 5/10/2022 10:24:51

AF22000913