Republic of the Philippines

Province of Aklan
HEALTH DECLARATION CARD

Tourists

a43899c0-3931-4288-a6e6-
d86de847bf70

Tourists
-- Please read before proceeding --
In compliance wit h RA 10173 or Dat a Privacy Act of t he Philippines, t he personal informat ion you will be providing in t his
form shall not be used for ot her purposes except for COVID-19 contact-tracing activities

a43899c 0-3931-4288-a6e6-d86de847bf 70 Arrival Dat e (yyyy-mm-dd): 2021-12-11

Email: enylemmor06@gmail.com Cont act No: 09201688198

Passport No/Valid ID Type & No: 0825050

Name: First Name Middle Name Last Name

ROMMELYNE CAO CRUZ
Nat ionalit y: FILIPINO Sex: F Birt hdat e (yyyy-mm-dd): 1992-10-06

Flight /Bus Number/Vessel Name: CEbu PACIFic 5J901 Seat No: -

Residence Address Street No. and Name of Street ( If applicable, indicate name of barangay)
(Philippines): 1164 ORION ST REET

Municipality/City Province Region

VALENZUELA VALENZUELA NCR
CITY
Count ry(ies) worked, visit ed and t ransit ed in t he last 30 days.

NA

HEALT H PROFILE
1. Have you been sick (cough, difficult y breat hing, colds, sore t hroat , fever) in t he past 30 days? [ ] Yes []No

2. Have you been exposed t o a confirmed case of COVID-19 ? days? [ ] Yes []No

3. Have you been t est ed posit ive for COVID-19 using RT-PCR Test ? [ ] Yes []No

Upon submit t ing, I am providing consent t o sharing my informat ion for cont act t racing purposes, I confirm t hat t he informat ion I have
given is true, correct and complete and t hat I underst and failure t o answer any quest ion may have serious consequences under
Philippines laws. (Art icle 171 and 172 of t he Revised Penal Code of t he Philippines)
Signature