Kawasan Industri Suryacipta Jl. Surya Madya VI, Kav.

I-58 C
Desa Kutanegara, Kec. Ciampel Kab. Karawang 41363 Jawa Barat
Telp : 0267 – 8637 900 Fax : 0267 – 8637 890
Filled in by visitor/diisi oleh tamu

A. Visitor Identity / Identitas Tamu

Name / Nama AGUS RINALDY Gender / Jenis Kelamin Male/Female
Nationality / Kewarganegaraan INDONESIAN Mobile Phone +62 878 – 8793 - 9734
Identity No / Nomor Identitas 3275112208980001
Company / Nama Perusahaan PT DDMI
Visit Date / Tanggal berkunjung 03 AUGUST 2022
Host PIC / Pengundang HR
Division / Divisi GA/HR

B. Please Fill-in Lingkari yg sesuai

1. Have visited overseas country, in the past 14 days before entering Indonesia?
(Telah mengunjungi negara di luar negeri, dalam 14 hari terakhir sebelum
masuk Indonesia?) YES NO
If answer is YES, which country :
(Jika jawabannya YA, negara mana) :

2. Had any contact with COVID-19 related patient in the past 14 days,
before your event day?
YES NO
(Apakah ada kontak dengan pasien terkait COVID-19 dalam 14 hari terakhir,
sebelum hari kedatangan Anda?)

3. Had you fever (≥ 37.5 C) in the past 7 day?

YES NO
( Apakah Anda demam (≥ 37,5 C) dalam 7 hari terakhir?)

4. Have following symptoms : Flu, Cough, Breathless, or sore throat

YES NO
(Mengalami gejala berikut: Flu, Batuk, sesak napas, dan sakit tenggorokan)

C. Filled by DDMI (GA Department)

Conclusion : ALLOW / DENY*
*choose one

Remarks GA/HR Div. Sign Guest Sign

- Valid at the same time (visiting)
- Please submit this form max. 1 day before arrival