VISITOR’S HEALTH DECLARATION FORM

Our company has been approved to operate under the C-MCO with the Approval Code Number O-00031387. In view of that we are obligated to
follow strict SOPs with regards to the Prevention, Protection and Contact Tracing against COVID-19 and to help our government efforts to stop the
transmission of this disease. Your cooperation and support in filling the below form truthfully is highly appreciated. Please do give a copy of your
Business Card when at our office, which will be stapled with the application declaration form for filing.

IMPORTANT NOTE:
Should there be an outbreak of COVID-19 at our office, the government has the right to take legal action, withdraw our operating license, close-down
our office and/or take any other related action.

PART A (GENERAL)

(1) Full Name:

(2) Gender: Male Female
(3) NRIC / Passport no.: (4) Age:
(5) Nationality:
(6) Mode of Transport: Air Sea Land
(7) Change same like staff: Vehicle Registration no.:
(8) Resident Address:

(9) Telephone no:

_________________________________________________________________________________________

PART B (COVID-19)

1) Have you been to any area or countries with COVID-19 as indicated by WHO, see Appendix 1, since 1st
March, 2020?
Yes No

2) Date of departure back to Malaysia from that said country? …………………………………….....

3) Have you been to any Red & Yellow COVID-19 Zones as indicated at Appendix 2, since 1st March, 2020?
Yes No

4) Have you been in direct or indirect contact with any of the Major COVID-19 Cluster Groups as indicated
at Appendix 3?
Yes No

5) Have you had any of the following symptoms over the past 30 days? Please tick if yes. If No please put
NO.
• Fever >37.5 C
• Dry Cough
• Difficulty in breathing
• Sore throat
• Loss sense of Smell
• Loss sense of Appetite
• Any other abnormal symptoms (please specify): ……………………………………

GreenTech Ventures International Sdn Bhd. (864370-M) PT. GreenTech International

C-18-3, The Link 2, Jalil Link 2, No. 5, Jalan Jalil Perkasa 1, Jl. Kebon Sirih Barat No. 3, Kel. Kebon Sirih, Kec. Menteng,
Bukit Jalil 57000 Kuala Lumpur, Malaysia. Kota Administrasi Jakarta Pusat, 10340, Indonesia.
GST No.: 0013 9656 3968 VAT No.: 03.256.120.1-021.000

Business Development: Mr. Jagdish Singh Gill Email: jagdishsingh.gill@greentechventures.com.my Mobile: +6-019-387 6507 / +62811 8389 886
Business Operations: Ms. Victoria Gill Email: victoria.gill@greentechventures.com.my Mobile: +6-019-2676507
Fax: 6-03-2732 5172 (Office)/ 6-03-2742 1877 (Home)
6) Have you been in close contact with any person suspected to have COVID-19?
Yes No

Definition close contact:

• Health care associated exposure, including providing direct care for COVID-19 patients, working with
health care workers infected with COVID-19, visiting patients or staying in the same close
environment of a COVID-19 patient.
• Working together in close proximity or sharing the same room environment with a with COVID19
patient.
• Traveling together with COVID-19 patient in any kind of conveyance.
• Living in the same household as a COVID-19 patient.

MOH, DOSH, MITI or any government authority may request for a copy of this form and you give us your
full consent to share the same should the government request so. The company reserves the right to take
legal action and seek compensation on any financial losses that the company may incur should there be
any outbreak of COVID-19 in our office due to your negligence, misinformation, hiding of information and
uncooperative conduct, with regards to these VISITOR’S HEALTH DECLARATION FORM.

Signature: ……………………….…………… Date: …………….…………

GreenTech Ventures International Sdn Bhd. (864370-M) PT. GreenTech International

C-18-3, The Link 2, Jalil Link 2, No. 5, Jalan Jalil Perkasa 1, Jl. Kebon Sirih Barat No. 3, Kel. Kebon Sirih, Kec. Menteng,
Bukit Jalil 57000 Kuala Lumpur, Malaysia. Kota Administrasi Jakarta Pusat, 10340, Indonesia.
GST No.: 0013 9656 3968 VAT No.: 03.256.120.1-021.000

Business Development: Mr. Jagdish Singh Gill Email: jagdishsingh.gill@greentechventures.com.my Mobile: +6-019-387 6507 / +62811 8389 886
Business Operations: Ms. Victoria Gill Email: victoria.gill@greentechventures.com.my Mobile: +6-019-2676507
Fax: 6-03-2732 5172 (Office)/ 6-03-2742 1877 (Home)
 APPENDIX 1:

USA Australia Niger

Spain Egypt Sri Lanka
Italy Malaysia Andorra
UK Finland Costa Rica
France Kuwait Lebanon
Germany Morocco Guatemala
Russia Argentina Diamond Princess
Turkey Algeria Mayotte
Brazil Moldova DRC (Democratic Republic of
Iran Kazakhstan the Congo)
China Luxembourg Sudan
Canada Bahrain Burkina Faso
Belgium Hungary Uruguay
Peru Thailand Georgia
India Afghanistan San Marino
Netherlands Nigeria Mali
Ecuador Ghana El Salvador
Switzerland Oman Channel Islands
Saudi Arabia Greece Maldives
Portugal Armenia Kenya
Mexico Iraq Tanzania
Sweden Uzbekistan Malta
Ireland Cameroon Jamaica
Pakistan Croatia Jordan
Chile Azerbaijan Taiwan
Singapore Bosnia and Herzegovina Reunion
Belarus Iceland Guinea-Bissau
Israel Guinea Paraguay
Qatar Estonia Gabon
Austria Bolivia Palestine
Japan Cuba Venezuela
UAE Bulgaria Mauritius
Poland North Macedonia Isle of Man
Romania New Zealand Montenegro
Ukraine Slovenia Equatorial Guinea
Indonesia Ivory Coast Vietnam
S. Korea Lithuania Rwanda
Bangladesh Slovakia Congo
Denmark Senegal Djibouti Tajikistan
Serbia Honduras Faeroe Islands
Philippines Hong Kong Martinique
Dominican Republic Tunisia Sierra Leone
Colombia Latvia Cabo Verde
Norway Cyprus Liberia
Czechia Kyrgyzstan Myanmar
South Africa Albania Guadeloupe
Panama Somalia Madagascar

GreenTech Ventures International Sdn Bhd. (864370-M) PT. GreenTech International

C-18-3, The Link 2, Jalil Link 2, No. 5, Jalan Jalil Perkasa 1, Jl. Kebon Sirih Barat No. 3, Kel. Kebon Sirih, Kec. Menteng,
Bukit Jalil 57000 Kuala Lumpur, Malaysia. Kota Administrasi Jakarta Pusat, 10340, Indonesia.
GST No.: 0013 9656 3968 VAT No.: 03.256.120.1-021.000

Business Development: Mr. Jagdish Singh Gill Email: jagdishsingh.gill@greentechventures.com.my Mobile: +6-019-387 6507 / +62811 8389 886
Business Operations: Ms. Victoria Gill Email: victoria.gill@greentechventures.com.my Mobile: +6-019-2676507
Fax: 6-03-2732 5172 (Office)/ 6-03-2742 1877 (Home)
 APPENDIX 1: (Continue)

Gibraltar Libya Namibia

Ethiopia French Polynesia Nicaragua
Brunei South Sudan Burundi
Zambia Macao Saint Kitts and Nevis
French Guiana Syria Falkland Islands
Togo Malawi Yemen
Cambodia Mongolia Turks and Caicos
Chad Eritrea Montserrat
Trinidad and Tobago Saint Martin Greenland
Eswatini Angola Vatican City
Bermuda Zimbabwe Seychelles
Haiti Antigua and Barbuda Suriname
Aruba Timor-Leste MS Zaandam
Uganda Sao Tome and Principe Mauritania
Benin Botswana Papua New Guinea
Monaco Grenada Bhutan
Guyana Laos British Virgin Islands
CAR (Central African Republic) Belize Caribbean Netherlands
Bahamas Fiji St. Barth
Barbados New Caledonia Western Sahara
Liechtenstein Saint Lucia Anguilla
Mozambique Gambia Comoros
Sint Maarten St. Vincent Grenadines Saint Pierre Miquelon
Cayman Islands Curacao
Nepal Dominica
_________________________________________________________________________________________

APPENDIX 2:

Ibu Kota Duta Setiawangsa

Batu Wangsa Maju Semarak
Kampung Bharu Setapak Salak Selatan
Sri Petaling Seputeh Cheras
Pandan Manjalara Bukit Jalil
Pudu Brickfields Bandar Tun Razak
Sentul Taman Desa
Lembah Pantai Sungai Besi
_________________________________________________________________________________________

APPENDIX 3:

Tabligh KL Wholesale Market Sungai Lui

Pesantren Students Church
Bandar Baru Ibrahim Majid Selangor Mansion

GreenTech Ventures International Sdn Bhd. (864370-M) PT. GreenTech International

C-18-3, The Link 2, Jalil Link 2, No. 5, Jalan Jalil Perkasa 1, Jl. Kebon Sirih Barat No. 3, Kel. Kebon Sirih, Kec. Menteng,
Bukit Jalil 57000 Kuala Lumpur, Malaysia. Kota Administrasi Jakarta Pusat, 10340, Indonesia.
GST No.: 0013 9656 3968 VAT No.: 03.256.120.1-021.000

Business Development: Mr. Jagdish Singh Gill Email: jagdishsingh.gill@greentechventures.com.my Mobile: +6-019-387 6507 / +62811 8389 886
Business Operations: Ms. Victoria Gill Email: victoria.gill@greentechventures.com.my Mobile: +6-019-2676507
Fax: 6-03-2732 5172 (Office)/ 6-03-2742 1877 (Home)