Scribd
Upload
75 views1 page

Travel & Declaration Form: Traveler: Self OR Member of Household

This travel declaration form collects travel and health information from Mark Beggie Sarmiento, an employee of Jatec Philippines corporation, in connection with the current coronavirus situation. It documents that Mr. Sarmiento traveled domestically within the Philippines from May 13-27, staying in Sta. Laguna, but had no international or household member travel in the past 14 days. He reported no symptoms of COVID-19. By signing, he consents to Texas Instruments collecting and sharing his personal data according to their privacy policies.

Uploaded by

Fatma Jelfa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
75 views1 page

Travel & Declaration Form: Traveler: Self OR Member of Household

This travel declaration form collects travel and health information from Mark Beggie Sarmiento, an employee of Jatec Philippines corporation, in connection with the current coronavirus situation. It documents that Mr. Sarmiento traveled domestically within the Philippines from May 13-27, staying in Sta. Laguna, but had no international or household member travel in the past 14 days. He reported no symptoms of COVID-19. By signing, he consents to Texas Instruments collecting and sharing his personal data according to their privacy policies.

Uploaded by

Fatma Jelfa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

TRAVEL & DECLARATION FORM

In connection to the current Corona Virus situation, we are requesting all TI (Philippines) Inc.
subcontractors to complete this declaration form pertaining to travel activities for yourself and any
relative or friends living in your household the past 14days.

Name : __MARK BEGGIE G. SARMIENTO _____________________________________________

XID : __Company_ID no. 03_____________________________________________

COMPANY : __Jatec Philippines corporation ( under Jeol Asia Pte. Ltd. Singapore )_______

INTERNATIONAL TRAVEL

Travel History for the Past 14days: (OUTSIDE the PHILIPPINES)


Traveler: Self OR Member of household
Date : _______none___________ to _____none________________
Country: ________________________________________
Date : ______________________ to _________________________
Country : ________________________________________

DOMESTIC TRAVEL

Travel History for the Past 14days: (WITHIN the PHILIPPINES)


Traveler: Self OR Member of household
Date : _______May 13,2020_____ to ___May 27,2020__________
Destination: ____sta laguna ( home ) ______________________
Date : ______________________ to _________________________
Destination : ________________________________________

Are you and/or your household experiencing any of the following symptoms? (Encircle your answer)

 Fever YES / NO
 Cough YES / NO
 Sore Throat YES / NO
 Colds YES / NO
 Body weakness YES / NO
 Difficulty of breathing YES / NO
 Diarrhea YES / NO

*Acknowledgement: “I understand that if I have any updates to this declaration, especially if I start to develop any of the symptoms
mentioned, I will immediately notify my manager and contact TI and the TI Health Center for assessment before reporting to work.”

By submitting this form, I agree that TI (Philippines) Inc. (“TI”) and its group of companies may collect, obtain, store and process my personal data for safety and health, security, and other
administrative purposes. Personal data includes all data defined within the Data Privacy Act of 2012, including all data I have disclosed to TI in this form. I give my consent to TI to disclose said
personal data to relevant governmental authorities or third parties where required by law or for legal purposes. In addition, I acknowledge and agree that my personal data may be transferred
to any company within the Texas Instruments group of companies, which may involve sending my data to a location outside the Philippines.

_____MARK BEGGIE SARMIENTO ______________ ____May 27,2020_____

PRINTED NAME & SIGNATURE DATE

You might also like