版本 : Ver. 7.0
* 身份證/護照號碼(ID/Passport No)：
* 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)
* 注意事項 :
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.
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.
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.