Health & Travel Declaration Form – Muslim Converts' Association of Singapore

Date of Submission *

Full Name *

NRIC/FIN/PASSPORT *

Contact Number *

Have you been to overseas during the last 14 days? *

Are you on MC/LOA/SHN/Quarantine Order? *

Do you have flu-like symptoms (e.g. fever, cough etc.)? *

Did you meet with someone who have been diagnosed with CoViD-19 or suspected or under quarantine order in the past 14 days? *

Temperature (measured at Temperature Taking Station) *

Phone