南亞科技防範「新型冠狀病毒肺炎」來賓、廠商健康聲明書
Nanya Technology Declaration against COVID-19(for Guests & Subcontractors)

版本 : Ver. 7.0

* 必填項目

* 姓名(Name):

* 身份證/護照號碼(ID/Passport No):

* 公司(Company):

   電子郵件(E-mail):

* 電話(Phone No.):

* 南亞科技經辦部門(Contact window of NTC):

* 1. 請問您過去21天是否曾有出國旅遊史Have you ever been abroad in the past 21 days?

* 2. 請問過去21天您是否有接觸確診(或疑似)病例?Have you ever contact any COVID-19 confirmed or suspected case in the past 21 days?

* 3. 請問您過去21天是否與居家隔離/ 居家檢疫、出國者有接觸? Have you ever contact any case of Home Quarantine, Isolation, or overseas traveler in the past 21 days?

* 4. 請問您是否於這21天內出現過以下症狀?(可複選)Have you had these symptoms during the past 21 days?(Checkable)

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* 注意事項 :
本人保證已如實填寫健康聲明書,如有隱匿或聲明不實而造成貴公司損失或影響貴公司員工、訪客或廠商健康之虞者,本人及其所屬公司同意連帶賠償貴公司或貴公司員工、訪客、廠商所受一切損害,並同意依照台塑企業規定將本人所屬公司列為拒絕往來對象。
I hereby declare, represent and warrant that all information or declaration I provided herein are true and accurate. In the event of any concealment or misrepresentation, I and the company I serve shall be jointly and severally liable to NTC and NTC’s employees, visitors and agents for any damages, expenses, or losses and I acknowledge that the company I serve will be debarred from doing any business with FPG.
本人了解上述聲明內容為貴公司核發本人防疫通行證之重要依據。本人持證期間,本人仍將持續關注中央流行疫情指揮中心或相關單位之公告。如本人之狀況改變致與上述聲明內容不符,或本人有應居家隔離、居家檢疫或自主健康管理之事由,本人應立即通知南亞科及本人所屬單位,並於南亞科再次同意前暫停進入南亞科。
I understand that my declaration as above is critical for NTC to review and issue the Prevention Pass. During my holding the Prevention Pass, I will continuously follow the information and directives released by Central Epidemic Command Center (CECC) or other agencies from time to time. Once my status cannot consist with the above declaration or I am subject to an order or requirement of quarantine, isolation, or self-health-management, I will immediately inform NTC and the company I serve, and will not enter NTC without further permission from NTC.
即日起所有來賓、訪客及廠商,凡與CDC公布案例足跡重疊者,進入本廠區需加強自主健康管理,全程配戴口罩並禁止參與會議或與他人共餐。
Anyone who ever contact with CDC confirmed case are requested to wear surgical facemask all the time, also not allow to attend meeting, eating/ drinking wth others once enter NTC.