Clean Camiguin Health Declaration Form

Camiguin Health Declaration Form

(Kindly fill out all the information needed and do not leave any box unmarked. Travelers are required to complete a Health Declaration Form.)

* - Required to fill-up.

Personal Information

Last Name: *

First Name: *

Middle Name:

CCQR Code: *

Birthday: *

Sex: *

Male

Female

Are you currently employed? * Yes No

Civil Status: *

Single

Married

Widowed

Nationality: *

Phone Number: *

Destination Address

Municipality/City: *

Barangay: *

Street/Sitio/Subdivision: House No./Lot/Bldg./Establishment: *

Travel Details to Province of Camiguin

How many days have you been outside the Province:

Tourist Travel Purpose: *

Transportation Type: *
AIR SEA

Date of Travel: *

Flight Type: *

Airline *

Flight Number *

Seat Number *

Stay period from: *

Stay period to: *

Date of Travel: *

Transport Type: *

Vehicle Type: *

Plate Number: *

Stay period from: *

Stay period to: *

Upload the Coordination Letter for Tourist (max file size 10MB, allowed extensions: .jpg, .png, .pdf) Upload your Confirmed Booking, Invitation, or Confirmation of Stay (max file size 10MB, allowed extensions: .jpg, .png, .pdf)

Upload your Vaccination ID/Card picture. (max file size 10MB, allowed extensions: .jpg, .png, .pdf)

* I hereby authorized the Province of Camiguin, to collect and process the above information for the purpose of effecting control of the COVID-19 infection. I understand that my personal information is protected by RA 10173, Data Privacy Act of 2012 and that I am required by RA 11449, Bayanihan to Heal as One Act, to provide TRUTHFUL information.

Camiguin Health Declaration Form

CCQR: *

Password: *

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Camiguin Health Declaration Form

Personal Information

Destination Address

Travel Details to Province of Camiguin

Upload the Coordination Letter for Tourist (max file size 10MB, allowed extensions: *.jpg, *.png, *.pdf)*

Upload your Confirmed Booking, Invitation, or Confirmation of Stay (max file size 10MB, allowed extensions: *.jpg, *.png, *.pdf)*

Upload your Vaccination ID/Card picture. (max file size 10MB, allowed extensions: *.jpg, *.png, *.pdf)*

Camiguin Health Declaration Form

Upload the Coordination Letter for Tourist (max file size 10MB, allowed extensions: .jpg, .png, .pdf)

Upload your Confirmed Booking, Invitation, or Confirmation of Stay (max file size 10MB, allowed extensions: .jpg, .png, .pdf)

Upload your Vaccination ID/Card picture. (max file size 10MB, allowed extensions: .jpg, .png, .pdf)